Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence.

PubMed

Hull, Tracy; Giese, Chad; Wexner, Steven D; Mellgren, Anders; Devroede, Ghislain; Madoff, Robert D; Stromberg, Katherine; Coller, John A

2013-02-01

Limited data have been published regarding the long-term results of sacral nerve stimulation, or sacral neuromodulation, for severe fecal incontinence. The aim was to assess the outcome of sacral nerve stimulation with the use of precise tools and data collection, focusing on the long-term durability of the therapy. Five-year data were analyzed. Patients entered in a multicenter, prospective study for fecal incontinence were followed at 3, 6, and 12 months and annually after device implantation. Patients with chronic fecal incontinence in whom conservative treatments had failed or who were not candidates for more conservative treatments were selected. Patients with ≥ 50% improvement over baseline in fecal incontinence episodes per week during a 14-day test stimulation period received sacral nerve stimulation therapy. Patients were assessed with a 14-day bowel diary and Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index questionnaires. Therapeutic success was defined as ≥ 50% improvement over baseline in fecal incontinence episodes per week. All adverse events were collected. A total of 120 patients (110 women; mean age, 60.5 years) underwent implantation. Seventy-six of these patients (63%) were followed a minimum of 5 years (maximum, longer than 8 years) and are the basis for this report. Fecal incontinence episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89% (n = 64/72) having ≥ 50% improvement (p < 0.0001) and 36% (n = 26/72) having complete continence. Fecal Incontinence Quality of Life scores also significantly improved for all 4 scales between baseline and 5 years (n = 70; p < 0.0001). Twenty-seven of the 76 (35.5%) patients required a device revision, replacement, or explant. The therapeutic effect and improved quality of life for fecal incontinence is maintained 5 years after sacral nerve stimulation implantation and beyond. Device revision, replacement, or explant rate was acceptable, but future efforts should be aimed at improvement.

Sacral Nerve Stimulation for Pediatric Lower Urinary Tract Dysfunction: Development of a Standardized Pathway with Objective Urodynamic Outcomes.

PubMed

Schober, Megan S; Sulkowski, Jason P; Lu, Peter L; Minneci, Peter C; Deans, Katherine J; Teich, Steven; Alpert, Seth A

2015-12-01

We propose that sacral nerve stimulation is a valid adjunctive therapy for refractory pediatric lower urinary tract dysfunction, and that prospective collection of preoperative and postoperative validated questionnaires and urodynamic data in a standardized fashion is beneficial in characterizing patient response. Patients were candidates for sacral nerve stimulation if they had refractory voiding dysfunction and standard treatments had failed. Preoperative evaluation included urodynamic studies, spinal magnetic resonance imaging, and validated bladder and bowel related questionnaires. Children were stratified into 2 groups, ie overactive bladder with or without incontinence (group 1) and detrusor underactivity/urinary retention requiring clean intermittent catheterization (group 2). A staged procedure was used with initial test lead placement, followed by permanent device insertion 2 weeks later if patients demonstrated symptom improvement with test lead. Postoperatively children were followed with questionnaires and at least 1 urodynamic study. A total of 26 children underwent sacral nerve stimulation. Mean patient age was 10.8 years and median followup was 1.2 years. There were 23 patients in group 1 and 4 in group 2 (1 patient was included in both groups). In group 1 voiding dysfunction scores improved significantly, and urodynamic studies revealed a significant decrease in mean number of uninhibited contractions and maximum detrusor pressure during the filling phase. In group 2 there was significant improvement in mean post-void residual. Sacral nerve stimulation is a treatment option that may produce significant improvement in objective and subjective measures of bladder function in children with refractory lower urinary tract dysfunction. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Medtronic, Inc.; premarket approval of the Interstim Sacral Nerve Stimulation (SNS) System--FDA. Notice.

PubMed

1998-01-29

The Food and Drug Administration (FDA) is announcing its approval of the application by Medtronic, Inc., Minneapolis, MN, for premarket approval, under the Federal Food, Drug, and Cosmetic Act (the act), of the Interstim Sacral Nerve Stimulation (SNS) System. After reviewing the recommendation of the Gastroenterology and Urology Devices Panel, FDA's Center for Devices and Radiological Health (CDRH) notified the applicant, by letter of September 29, 1997, of the approval of the application.

Extracorporeal Stimulation of Sacral Nerve Roots for Observation of Pelvic Autonomic Nerve Integrity: Description of a Novel Methodological Setup.

PubMed

Moszkowski, Tomasz; Kauff, Daniel W; Wegner, Celine; Ruff, Roman; Somerlik-Fuchs, Karin H; Kruger, Thilo B; Augustyniak, Piotr; Hoffmann, Klaus-Peter; Kneist, Werner

2018-03-01

Neurophysiologic monitoring can improve autonomic nerve sparing during critical phases of rectal cancer surgery. To develop a system for extracorporeal stimulation of sacral nerve roots. Dedicated software controlled a ten-electrode stimulation array by switching between different electrode configurations and current levels. A built-in impedance and current level measurement assessed the effectiveness of current injection. Intra-anal surface electromyography (sEMG) informed on targeting the sacral nerve roots. All tests were performed on five pig specimens. During switching between electrode configurations, the system delivered 100% of the set current (25 mA, 30 Hz, 200 μs cathodic pulses) in 93% of 250 stimulation trains across all specimens. The impedance measured between single stimulation array contacts and corresponding anodes across all electrode configurations and specimens equaled 3.7 ± 2.5 kΩ. The intra-anal sEMG recorded a signal amplitude increase as previously observed in the literature. When the stimulation amplitude was tested in the range from 1 to 21 mA using the interconnected contacts of the stimulation array and the intra-anal anode, the impedance remained below 250 Ω and the system delivered 100% of the set current in all cases. Intra-anal sEMG showed an amplitude increase for current levels exceeding 6 mA. The system delivered stable electric current, which was proved by built-in impedance and current level measurements. Intra-anal sEMG confirmed the ability to target the branches of the autonomous nervous system originating from the sacral nerve roots. Stimulation outside of the operative field during rectal cancer surgery is feasible and may improve the practicality of pelvic intraoperative neuromonitoring.

Anatomical organization and somatic axonal components of the lumbosacral nerves in female rabbits.

PubMed

Cruz, Yolanda; Hernández-Plata, Isela; Lucio, Rosa Angélica; Zempoalteca, René; Castelán, Francisco; Martínez-Gómez, Margarita

2017-09-01

To determine the anatomical organization and somatic axonal components of the lumbosacral nerves in female rabbits. Chinchilla adult anesthetized female rabbits were used. Anatomical, electrophysiological, and histological studies were performed. L7, S1, and some fibers from S2 and S3 form the lumbosacral trunk, which gives origin to the sciatic nerve and innervation to the gluteal region. From S2 to S3 originates the pudendal nerve, whose branches innervates the striated anal and urethra sphincters, as well as the bulbospongiosus, ischiocavernosus, and constrictor vulvae muscles. The sensory field of the pudendal nerve is ∼1800 mm 2 and is localized in the clitoral sheath and perineal and perigenital skin. The organization of the pudendal nerve varies between individuals, three patterns were identified, and one of them was present in 50% of the animals. From S3 emerge the pelvic nerve, which anastomoses to form a plexus localized between the vagina and the rectum. The innervation of the pelvic floor originates from S3 to S4 fibers. Most of the sacral spinal nerves of rabbit are mixed, carrying sensory, and motor information. Sacral nerves innervate the hind limbs, pelvic viscera, clitoris, perineal muscles, inguinal and anal glands and perineal, perigenital, and rump skin. The detailed description of the sacral nerves organization, topography, and axonal components further the knowledge of the innervation in pelvic and perinal structures of the female rabbit. This information will be useful in future studies about the physiology and physiopathology of urinary, fecal, reproductive, and sexual functions. © 2017 Wiley Periodicals, Inc.

Exhausted implanted pulse generator in sacral nerve stimulation for faecal incontinence: What next in daily practice for patients?

PubMed

Duchalais, Emilie; Meurette, Guillaume; Perrot, Bastien; Wyart, Vincent; Kubis, Caroline; Lehur, Paul-Antoine

2016-02-01

The efficacy of sacral nerve stimulation in faecal incontinence relies on an implanted pulse generator known to have a limited lifespan. The long-term use of sacral nerve stimulation raises concerns about the true lifespan of generators. The aim of the study was to assess the lifespan of sacral nerve stimulation implanted pulse generators in daily practice, and the outcome of exhausted generator replacement, in faecal incontinent patients. Faecal incontinent patients with pulse generators (Medtronic Interstim™ or InterstimII™) implanted in a single centre from 2001 to 2014 were prospectively followed up. Generator lifespan was measured according to the Kaplan-Meier method. Patients with a generator explanted/turned off before exhaustion were excluded. Morbidity of exhausted generator replacement and the outcome (Cleveland Clinic Florida Faecal Incontinence (CCF-FI) and Faecal Incontinence Quality of Life (FIQL) scores) were recorded. Of 135 patients with an implanted pulse generator, 112 (InterstimII 66) were included. Mean follow-up was 4.9 ± 2.8 years. The generator reached exhaustion in 29 (26%) cases. Overall median lifespan of an implanted pulse generator was approximately 9 years (95% CI 8-9.2). Interstim and InterstimII 25th percentile lifespan was 7.2 (CI 6.4-8.3) and 5 (CI 4-not reached) years, respectively. After exhaustion, generators were replaced, left in place or explanted in 23, 2 and 4 patients, respectively. Generator replacement was virtually uneventful. CCF-FI/FIQL scores remained unchanged after generator replacement (CCF-FI 8 ± 2 vs 7 ± 3; FIQL 3 ± 0.6 vs 3 ± 0.5; p = ns). In this study, the implanted pulse generator observed median lifespan was 9 years. After exhaustion, generators were safely and efficiently replaced. The study also gives insight into long-term needs and costs of sacral nerve stimulation (SNS) therapy.

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment

PubMed Central

2017-01-01

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%–80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making. PMID:29159162

Threshold dose for peripheral neuropathy following intraoperative radiotherapy (IORT) in a large animal model

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kinsella, T.J.; DeLuca, A.M.; Barnes, M.

1991-04-01

Radiation injury to peripheral nerve is a dose-limiting toxicity in the clinical application of intraoperative radiotherapy, particularly for pelvic and retroperitoneal tumors. Intraoperative radiotherapy-related peripheral neuropathy in humans receiving doses of 20-25 Gy is manifested as a mixed motor-sensory deficit beginning 6-9 months following treatment. In a previous experimental study of intraoperative radiotherapy-related neuropathy of the lumbro-sacral plexus, an approximate inverse linear relationship was reported between the intraoperative dose (20-75 Gy range) and the time to onset of hind limb paresis (1-12 mos following intraoperative radiotherapy). The principal histological lesion in irradiated nerve was loss of large nerve fibers andmore » perineural fibrosis without significant vascular injury. Similar histological changes in irradiated nerves were found in humans. To assess peripheral nerve injury to lower doses of intraoperative radiotherapy in this same large animal model, groups of four adult American Foxhounds received doses of 10, 15, or 20 Gy to the right lumbro-sacral plexus and sciatic nerve using 9 MeV electrons. The left lumbro-sacral plexus and sciatic nerve were excluded from the intraoperative field to allow each animal to serve as its own control. Following treatment, a complete neurological exam, electromyogram, and nerve conduction studies were performed monthly for 1 year. Monthly neurological exams were performed in years 2 and 3 whereas electromyogram and nerve conduction studies were performed every 3 months during this follow-up period. With follow-up of greater than or equal to 42 months, no dog receiving 10 or 15 Gy IORT shows any clinical or laboratory evidence of peripheral nerve injury. However, all four dogs receiving 20 Gy developed right hind limb paresis at 8, 9, 9, and 12 mos following intraoperative radiotherapy.« less

Reduction and temporary stabilization of Tile C pelvic ring injuries using a posteriorly based external fixation system.

PubMed

Martin, Murphy P; Rojas, David; Mauffrey, Cyril

2018-07-01

Tile C pelvic ring injuries are challenging to manage even in the most experienced hands. The majority of such injuries can be managed using percutaneous reduction techniques, and the posterior ring can be stabilized using percutaneous transiliac-transsacral screw fixation. However, a subgroup of patients present with inadequate bony corridors, significant sacral zone 2 comminution or significant lateral/vertical displacement of the hemipelvis through a complete sacral fracture. Percutaneous strategies in such circumstances can be dangerous. Those patients may benefit from prone positioning and open reduction of the sacral fracture with fixation through tension band plating or lumbo-pelvic fixation. Soft tissue handling is critical, and direct reduction techniques around the sacrum can be difficult due to the complex anatomy and the fragile nature of the sacrum making clamp placement and tightening a challenge. In this paper, we propose a mini-invasive technique of indirect reduction and temporary stabilization, which is soft tissue friendly and permits maintenance of reduction during definitive fixation surgical.

F-18 FDG PET/CT findings of a case of sacral nerve root neurolymphomatosis that occurred during chemotherapy.

PubMed

Suga, Kazuyoshi; Yasuhiko, Kawakami; Matsunaga, Naofumi; Yujiri, Toshiaki; Nakazora, Tatsuki; Ariyoshi, Kouichi

2011-01-01

Neurolymphomatosis (NL) is a rare, unique subtype of lymphomatous infiltration of peripheral nerves. Clinical/radiologic diagnosis of NL is challenging. We report F-18 FDG PET/CT findings of a case of breast diffuse large B-cell lymphoma, in which NL developed regardless of regression of systemic lesions during induction chemotherapy. FDG PET/CT showed characteristic findings of well-demarcated, linear abnormal FDG uptake along a sacral vertebral foramen, leading to diagnosis of NL, with the finding of thickened nerve roots on magnetic resonance imaging. Altered chemotherapeutic regimen resulted in disappearance of these abnormal FDG uptake, with recovery of neurologic symptoms. Peripheral nerve NL may occur during chemotherapy, and FDG PET/CT can be a useful imaging modality in diagnosis and monitoring of therapeutic response of this disease.

Acute urinary retention attributable to sacral herpes zoster.

PubMed

Acheson, J; Mudd, D

2004-11-01

Acute urinary retention in women is uncommon. A 63 year old woman presented with suprapubic pain, a palpable bladder, and multiple grouped vesicles on the right buttock. Catheterisation showed a residual of 2000 ml. A case is reported of acute urinary retention secondary to herpes zoster infection of the sacral nerves (S2-4).

Long-term results of sacral neuromodulation for women with urinary retention.

PubMed

Dasgupta, Ranan; Wiseman, Oliver J; Kitchen, Neil; Fowler, Clare J

2004-08-01

OBJECTIVE ; To review the long-term results of sacral nerve stimulation in the treatment of women with Fowler's syndrome, over a 6-year period at one tertiary referral centre. Between 1996 and 2002, 26 women with urinary retention were treated by implanting a sacral nerve stimulator. Their case records were reviewed for follow-up, complications and revision procedures, and the most recent uroflowmetry results. There were 20 patients (77%) still voiding spontaneously at the time of review (with two having deactivated their stimulator because of pregnancy). Fourteen patients (54%) required revision surgery, and the most common complications included loss of efficacy, implant-related discomfort and leg pain. The mean postvoid residual volume was 75 mL and mean maximum flow rate 20.8 mL/s. In young women with retention, for whom there is still no alternative to lifelong self-catheterization, sacral neuromodulation is effective for up to 5 years after implantation. However, there was a significant complication rate, in line with other reports, which may be improved by new technical developments.

Urinary Incontinence Surgery: When Other Treatments Aren't Enough

MedlinePlus

... surgery. Certain procedures to treat overactive bladder involve stimulation — using small, electrical impulses — of the nerves that signal the need to urinate. Sacral nerve stimulation. Your surgeon implants a small, pacemaker-like device ...

[Sacral nerve stimulation in the treatment of the lower urinary tract function disorders].

PubMed

Miotła, Paweł; Kulik-Rechberger, Beata; Skorupski, Paweł; Rechberger, Tomasz

2011-11-01

Functional disorders of the female lower urinary tract like urge incontinence, idiopathic urinary retention and symptoms of urgency-frequency occasionally do not respond properly to classical behavioral and pharmacological therapy Therefore, additional alternative therapies are needed to alleviate these bothersome symptoms. Sacral neuromodulation (SNS) utilize mild electrical pulses which activate or suppress neural reflexes responsible for voiding by stimulating the sacral nerves that innervate the bladder, external urethral sphincter and pelvic floor muscles. The exact mechanism of SNS action is not yet fully understood but it is assumed that it influences the neuroaxis at different levels of the central nervous system and restores the balance between inhibitory and activatory control over the voiding reflex. There is numerous evidence on the success of SNS not only in the treatment of refractory urge incontinence in adult and children but also in idiopathic urinary retention and symptoms of urgency-frequency

α-Synuclein pathology in the cranial and spinal nerves in Lewy body disease.

PubMed

Nakamura, Keiko; Mori, Fumiaki; Tanji, Kunikazu; Miki, Yasuo; Toyoshima, Yasuko; Kakita, Akiyoshi; Takahashi, Hitoshi; Yamada, Masahito; Wakabayashi, Koichi

2016-06-01

Accumulation of phosphorylated α-synuclein in neurons and glial cells is a histological hallmark of Lewy body disease (LBD) and multiple system atrophy (MSA). Recently, filamentous aggregations of phosphorylated α-synuclein have been reported in the cytoplasm of Schwann cells, but not in axons, in the peripheral nervous system in MSA, mainly in the cranial and spinal nerve roots. Here we conducted an immunohistochemical investigation of the cranial and spinal nerves and dorsal root ganglia of patients with LBD. Lewy axons were found in the oculomotor, trigeminal and glossopharyngeal-vagus nerves, but not in the hypoglossal nerve. The glossopharyngeal-vagus nerves were most frequently affected, with involvement in all of 20 subjects. In the spinal nerve roots, Lewy axons were found in all of the cases examined. Lewy axons in the anterior nerves were more frequent and numerous in the thoracic and sacral segments than in the cervical and lumbar segments. On the other hand, axonal lesions in the posterior spinal nerve roots appeared to increase along a cervical-to-sacral gradient. Although Schwann cell cytoplasmic inclusions were found in the spinal nerves, they were only minimal. In the dorsal root ganglia, axonal lesions were seldom evident. These findings indicate that α-synuclein pathology in the peripheral nerves is axonal-predominant in LBD, whereas it is restricted to glial cells in MSA. © 2015 Japanese Society of Neuropathology.

Vascular Entrapment of Both the Sciatic and Pudendal Nerves Causing Persistent Sciatica and Pudendal Neuralgia.

PubMed

Kale, Ahmet; Basol, Gulfem; Usta, Taner; Cam, Isa

2018-04-24

To demonstrate the laparoscopic approach to malformed branches of the vessels entrapping the nerves of the sacral plexus. A step-by-step explanation of the surgery using video (educative video) (Canadian Task force classification II). The university's Ethics Committee ruled that approval was not required for this video. Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey. A 26-year-old patient who had failed medical therapy and presented with complaints of numbness and burning pain on the right side of her vagina and pain radiating to her lower limbs for a period of approximately 36 months. The peritoneum was incised along the external iliac vessels, and these vessels were separated from the iliopsoas muscle on the right side of the pelvis. The laparoscopic decompression of intrapelvic vascular entrapment was performed at 3 sites: the lumbosacral trunk, sciatic nerve, and pudendal nerve. The aberrant dilated veins were gently dissected from nerves, and then coagulated and cut with the LigaSure sealing device (Medtronic, Minneapolis, Minn). The operation was completed successfully with no complications, and the patient was discharged from the hospital 24 hours after the operation. At a 6-month follow-up, she reported complete resolution of dyspareunia and sciatica (visual analog scale score 1 of 10). A less well-known cause of chronic pelvic pain is compression of the sacral plexus by dilated or malformed branches of the internal iliac vessels. Laparoscopic management of vascular entrapment of the sacral plexus has been described by Possover et al [1,2] and Lemos et al [3]. This procedure appears to be feasible and effective, but requires significant experience and familiarity with laparoscopy techniques and pelvic nerve anatomy. Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.

Rectal ulcer in a patient with VZV sacral meningoradiculitis (Elsberg syndrome).

PubMed

Matsumoto, Hideyuki; Shimizu, Takahiro; Tokushige, Shin-ichi; Mizuno, Hideo; Igeta, Yukifusa; Hashida, Hideji

2012-01-01

This report describes the case of a 55-year-old woman with varicella-zoster virus (VZV) sacral meningoradiculitis (Elsberg syndrome) who presented with herpes zoster in the left S2 dermatome area, urinary retention, and constipation. Lumbar magnetic resonance imaging showed the left sacral nerve root swelling with enhancement. Thereafter, she suddenly showed massive hematochezia and hemorrhagic shock because of a rectal ulcer. To elucidate the relation between Elsberg syndrome and rectal ulcer, accumulation of similar cases is necessary. To avoid severe complications, attention must be devoted to the possibility of rectal bleeding in the early stage of Elsberg syndrome.

Sacral root neuromodulation in idiopathic nonobstructive chronic urinary retention.

PubMed

Shaker, H S; Hassouna, M

1998-05-01

Sacral root neuromodulation is becoming a superior alternative to the standard treatment of idiopathic nonobstructive urinary retention. We report results in 20 successive patients who underwent sacral foramen implantation to restore bladder function. After an initial, thorough baseline assessment 20 patients 19.43 to 55.66 years old with idiopathic nonobstructive urinary retention underwent percutaneous nerve evaluation. Response was assessed by a detailed voiding diary. Responders underwent implantation with an S3 foramen implant, and were followed 1, 3 and 6 months postoperatively, and every 6 months thereafter. Sacral root neuromodulation restored voiding capability in these patients. Bladders were emptied with minimal post-void residual urine, which decreased from 78.3 to 5.5 to 10.2% of the total voided volume from baseline to postoperative followup. These results were reflected in uroflowmetry and pressure-flow studies, which were almost normal after implantation. Furthermore, the urinary tract infection rate decreased significantly and associated pelvic pain improved substantially. The Beck depression inventory and SF-36 quality of life questionnaire indicated some improvement but reached significance in only 1 item. In addition, cystometrography showed no significant difference after 6 months of implantation compared with baseline values. Complications were minimal and within expectations. Sacral root neuromodulation is an appealing, successful modality for nonobstructive urinary retention. Only patients who have a good response to percutaneous nerve evaluation are candidates for implantation. The high efficacy in patients who undergo implantation, relative simplicity of the procedure and low complication rate make this a treatment breakthrough in this difficult group.

Transcutaneous sacral neurostimulation for irritative voiding dysfunction.

PubMed

Walsh, I K; Johnston, R S; Keane, P F

1999-01-01

Patients with irritative voiding dysfunction are often unresponsive to standard clinical treatment. We evaluated the response of such individuals to transcutaneous electrical stimulation of the third sacral nerve. 32 patients with refractory irritative voiding dysfunction (31 female and 1 male; mean age 47 years) were recruited to the study. Ambulatory transcutaneous electrical neurostimulation was applied bilaterally to the third sacral dermatomes for 1 week. Symptoms of frequency, nocturia, urgency, and bladder pain were scored by each patient throughout and up to 6 months following treatment. The mean daytime frequency was reduced from 11.3 to 7.96 (p = 0.01). Nocturia episodes were reduced from a mean of 2.6 to 1.8 (p = 0.01). Urgency and bladder pain mean symptom scores were reduced from 5.97 to 4.89 and from 1.48 to 0.64, respectively. After stopping therapy, symptoms returned to pretreatment levels within 2 weeks in 40% of the patients and within 6 months in 100%. Three patients who continued with neurostimulation remained satisfied with this treatment modality at 6 months. Transcutaneous third sacral nerve stimulation may be an effective and noninvasive ambulatory technique for the treatment of patients with refractory irritative voiding dysfunction. Following an initial response, patients may successfully apply this treatment themselves to ensure long-term relief.

Mechanisms underlying recurrent inhibition in the sacral parasympathetic outflow to the urinary bladder.

PubMed Central

de Groat, W C

1976-01-01

1. In cats with the sacral dorsal roots cut on one side electrical stimulation (15-40 c/s) of the central end of the transected ipsilateral pelvic nerve depressed spontaneous bladder contractions. The depression was abolished by transecting the ipsilateral sacral ventral roots. 2. Electrical stimulation of acutely or chronically transected ('deafferented') sacral ventral roots depressed spontaneous bladder contractions and the firing of sacral parasympathetic preganglionic neurones innervating the bladder. The depression of neuronal firing occurred ipsilateral and contralateral to the point of stimulation, but only occurred with stimulation of sacral roots containing preganglionic axons and only with stimulation of sacral roots containing preganglionic axons and only at intensities of stimulation (0-7-4V) above the threshold for activation of these axons. 3. The inhibitory responses were not abolished by strychnine administered by micro-electrophoresis to preganglionic neurones, but were blocked by the intravenous administration of strychnine. 4. The firing of preganglionic neurones elicited by micro-electrophoretic administration of an excitant amino acid (DL-homocysteic acid) was not depressed by stimulation of the ventral roots. 5. It is concluded that the inhibition of the sacral outflow to the bladder by stimulation of sacral ventral roots is related to antidromic activation of vesical preganglionic axons. Collaterals of these axons must excite inhibitory interneurones which in turn depress transmission at a site on the micturition reflex pathway prior to the preganglionic neurones. PMID:950603

A urodynamic study of surface neuromodulation versus sham in detrusor instability and sensory urgency.

PubMed

Bower, W F; Moore, K H; Adams, R D; Shepherd, R

1998-12-01

We studied the effect of surface neuromodulation on cystometric pressure and volume parameters in women with detrusor instability or sensory urgency. Electrical current was delivered to the suprapubic region and third sacral foramina via a transcutaneous electrical nerve stimulator with sham neuromodulation control. A consecutive series of women with proved detrusor instability or sensory urgency were randomized to 3 surface neuromodulation groups. Volume and pressure parameters were the main outcomes of transcutaneous electrical nerve stimulation applied during second cystometric fill. Sham transcutaneous electrical nerve stimulation did not alter the outcome measures. However, neuromodulation delivered across the suprapubic and sacral skin effected a reduction in mean maximum height of detrusor contraction. A current which inhibits motor activity was not superior to that which inhibits sensory perception in reducing detrusor pressure. Response in sensory urgency was poor. Results from our sham controlled study suggest that short-term surface neuromodulation via transcutaneous electrical nerve stimulation may have a role in the treatment of detrusor instability. Future studies must examine the clinical effect of long-term surface neuromodulation.

Experimental results on mechanisms of action of electrical neuromodulation in chronic urinary retention.

PubMed

Schultz-Lampel, D; Jiang, C; Lindström, S; Thüroff, J W

1998-01-01

Sacral foramen neuromodulation--initially applied for the treatment of urinary incontinence--has proved to be effective in patients with chronic urinary retention. Thus far, the underlying neurophysiological mechanisms have not been elucidated. In an experimental study on the neurophysiological basis of sacral neurostimulation, one objective was to investigate the mechanisms responsible for initiation of micturition in chronic urinary retention. In ten female cats anesthetized with alpha-chloralose the clinical situation of sacral foramen stimulation was experimentally reproduced by isolated S2 nerve stimulation after L6-S3 laminectomy. Stimulation responses were recorded from the bladder, peripheral nerves, and striated muscles of the foot and pelvic floor. The effect of sudden cessation of prolonged S2 stimulation, during which the bladder was completely inhibited, was evaluated in 70 stimulation sequences in 5 cats. Sacral nerve stimulation induced excitatory and inhibitory effects on the bladder, depending on the frequency and intensity of stimulation. With unilateral S2 stimulation, bladder excitation was best at frequencies of 2-5 Hz and at intensities ranging between 0.8 and 1.4 times the threshold for the M-response of the foot muscle. Inhibition was the dominating effect at frequencies of 7-10 Hz and at intensities exceeding 1.4 times the threshold. Prolonged S2 stimulation above the threshold produced complete bladder inhibition during stimulation but induced strong bladder contractions after sudden interruption of stimulation, with amplitudes being significantly higher than that of spontaneous contractions preceding the stimulation. These results confirm the hypothesis of a "rebound" phenomenon as the mechanism of action for induction of spontaneous voiding in patients with chronic urinary retention.

Sacral root neuromodulation in the treatment of various voiding and storage problems.

PubMed

Shaker, H; Hassouna, M M

1999-01-01

This paper reviews the use of sacral neuromodulation as a treatment modality for patients with bladder dysfunction. The dual functions of the urinary bladder are to act as a reservoir and to evacuate under voluntary control. Bladder dysfunction is a descriptive term describing the loss or the impairment of one or both of these functions. In the first part of the manuscript we describe the different components of sacral neuromodulation: the screening test known as percutaneous nerve evaluation (PNE), which involves screening patients who could potentially benefit from the therapy. Those who show a satisfactory response will have a permanent neuroprosthesis implanted. The technical aspects of both components of neuromodulation are described in detail, as well as the technical difficulties encountered. In the second part we present our long-term results in patients with sacral neuromodulation. Sacral neuromodulation is a safe and efficient therapeutic modality that helps patients with refractory voiding dysfunction restore their bladder function.

Acute urinary retention due to benign inflammatory nervous diseases.

PubMed

Sakakibara, Ryuji; Yamanishi, Tomonori; Uchiyama, Tomoyuki; Hattori, Takamichi

2006-08-01

Both neurologists and urologists might encounter patients with acute urinary retention due to benign inflammatory nervous diseases. Based on the mechanism of urinary retention, these disorders can be divided into two subgroups: disorders of the peripheral nervous system (e.g., sacral herpes) or the central nervous system (e.g., meningitis-retention syndrome [MRS]). Laboratory abnormalities include increased herpes virus titers in sacral herpes, and increased myelin basic protein in the cerebrospinal fluid (CSF) in some cases with MRS. Urodynamic abnormality in both conditions is detrusor areflexia; the putative mechanism of it is direct involvement of the pelvic nerves in sacral herpes; and acute spinal shock in MRS. There are few cases with CSF abnormality alone. Although these cases have a benign course, management of the acute urinary retention is necessary to avoid bladder injury due to overdistension. Clinical features of sacral herpes or MRS differ markedly from those of the original "Elsberg syndrome" cases.

Incidentally diagnosed giant invasive sacral schwannoma

PubMed Central

Togral, Guray; Arikan, Murat; Hasturk, Askin E.; Gungor, Safak

2014-01-01

Schwannomas are benign encapsulated tumors of Schwan cells that grow slowly along the peripheral myelin nerve fibers. Sacral spinal schwannomas are very rare, and the incidence of sacral schwannoma ranges from 1-5% of all spinal schwannomas, and only around 50 cases are reported in the literature. There are 3 defined types of sacral schwannomas. These are retroperitoneal or presacral, intra osseous, and spinal schwannomas. Patients commonly present with complaints of pain and paresthesia due to the spinal schwannoma extending to extra spinal tissues. Direct x-ray, CT, MRI, and scintigraphy are used for preoperative diagnosis and treatment planning. Local recurrence and transformation to malignancy is very rare. For this reason, the frequently preferred treatments are subtotal removal of the mass or simple enucleation. In our article, we discuss the clinical features and the surgical treatment we performed without the need for stabilization in an incidentally determined giant invasive schwannoma case. PMID:24983285

PubMed Central

N., Chuchueva; C., Gerosa; S., Sionis; R.A., Caria; R., Puxeddu

2017-01-01

SUMMARY Temporary and permanent facial nerve dysfunctions can be observed after parotidectomy for benign and malignant lesions. Intraoperative nerve monitoring is a recognised tool for the preservation of the nerve, while the efficacy of the operative microscope has been rarely stated. The authors report their experience on 198 consecutive parotidectomies performed on 196 patients with the aid of the operative microscope and intraoperative nerve monitoring. 145 parotidectomies were performed for benign lesions and 53 for malignancies. Thirteen patients treated for benign tumours experienced temporary (11 cases) or permanent facial palsy (2 cases, both of House-Brackmann grade II). Ten patients with malignant tumour presented with preoperative facial nerve weakness that did not improve after treatment. Five and 6 patients with malignant lesion without preoperative facial nerve deficit experienced postoperative temporary and permanent weakness respectively (the sacrifice of a branch of the nerve was decided intraoperatively in 2 cases). Long-term facial nerve weakness after parotidectomy for lesions not directly involving or originating from the facial nerve (n = 185) was 2.7%. Patients treated for benign tumours of the extra facial portion of the gland without inflammatory behaviour (n = 91) had 4.4% facial nerve temporary weakness rate and no permanent palsy. The combined use of the operative microscope and intraoperative nerve monitoring seems to guarantee facial nerve preservation during parotidectomy. PMID:29165432

Microstructural Changes in Compressed Nerve Roots Are Consistent With Clinical Symptoms and Symptom Duration in Patients With Lumbar Disc Herniation.

PubMed

Wu, Weifei; Liang, Jie; Ru, Neng; Zhou, Caisheng; Chen, Jianfeng; Wu, Yongde; Yang, Zong

2016-06-01

A prospective study. To investigate the association between microstructural nerve roots changes on diffusion tensor imaging (DTI) and clinical symptoms and their duration in patients with lumbar disc herniation. The ability to identify microstructural properties of the nervous system with DTI has been demonstrated in many studies. However, there are no data regarding the association between microstructural changes evaluated using DTI and symptoms assessed with the Oswestry Disability Index (ODI) and their duration. Forty consecutive patients with foraminal disc herniation affecting unilateral sacral 1 (S1) nerve roots were enrolled in this study. DTI with tractography was performed on the S1 nerve roots. Clinical symptoms were evaluated using an ODI questionnaire for each patient, and the duration of clinical symptoms was noted based on the earliest instance of leg pain and numbness. Mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated from tractography images. The mean FA value of the compressed lumbar nerve roots was significantly lower than the FA of the contralateral nerve roots (P < 0.001). No notable difference in ADC was observed between compressed nerve roots and contralateral nerve roots (P = 0.517). In the compressed nerve roots, a significant negative association was observed between FA values and ODI and symptom duration. However, an obvious positive association was observed between ODI and ADC values and duration on the compressed side. Significant changes in diffusion parameters were found in the compressed sacral nerves in patients with lumbar disc herniation and leg pain, indicating that the microstructure of the nerve root has been damaged. 3.

An animal model for the neuromodulation of neurogenic bladder dysfunction.

PubMed

Zvara, P; Sahi, S; Hassouna, M M

1998-08-01

To develop an animal model to examine the pathophysiology by which S3 sacral root electrostimulation alters the micturition reflex in patients with bladder hyper-reflexia. Chronic sacral nerve root electrostimulation was applied to spinally transected rats; 21 animals were divided into four groups. The spinal cord was completely transected at the T10-11 level and stainless-steel electrodes implanted into the sacral foramen in 17 animals; these animals were subsequently divided into two groups (1 and 2). Six rats in group 1 underwent sacral root elctrostimulation for 2 h/day and five in group 2 for 6 h/day, for 21 days. The sham group (group 3, six rats) received no stimulation and four rats were used as healthy controls (group 4). Voiding frequency was recorded and each animal was evaluated cystometrically at the end of the stimulation period. The results were compared with the sham and control groups. Spinal cord transection resulted in bladder areflexia and complete urinary retention; 7-9 days after the injury, the bladder recovered its activity. Twenty-one days after transection all animals had evidence of uninhibited bladder contractions. The mean (SD) hourly frequency of urination was 0.66 (0.18) in healthy controls, 0.83 (0.21) in group 1, 0.87 (0.34) in group 2 and 1.1 (0.31) in group 3. There was a significant decrease in eh cystometric signs of bladder hyper-reflexia in groups 1 and 2 when compared with group 3. This work reports and initial study showing that chronic electrostimulation of sacral nerve roots can reduce the signs of bladder hyper-reflexia in the spinally injured rat. To our knowledge, this is the first report describing the rat as an animal model to determine the effects of chronic electrostimulation on the micturition reflex.

Parotid tumours: clinical and oncologic outcomes after microscope-assisted parotidectomy with intraoperative nerve monitoring.

PubMed

Carta, F; Chuchueva, N; Gerosa, C; Sionis, S; Caria, R A; Puxeddu, R

2017-10-01

Temporary and permanent facial nerve dysfunctions can be observed after parotidectomy for benign and malignant lesions. Intraoperative nerve monitoring is a recognised tool for the preservation of the nerve, while the efficacy of the operative microscope has been rarely stated. The authors report their experience on 198 consecutive parotidectomies performed on 196 patients with the aid of the operative microscope and intraoperative nerve monitoring. 145 parotidectomies were performed for benign lesions and 53 for malignancies. Thirteen patients treated for benign tumours experienced temporary (11 cases) or permanent facial palsy (2 cases, both of House-Brackmann grade II). Ten patients with malignant tumour presented with preoperative facial nerve weakness that did not improve after treatment. Five and 6 patients with malignant lesion without preoperative facial nerve deficit experienced postoperative temporary and permanent weakness respectively (the sacrifice of a branch of the nerve was decided intraoperatively in 2 cases). Long-term facial nerve weakness after parotidectomy for lesions not directly involving or originating from the facial nerve (n = 185) was 2.7%. Patients treated for benign tumours of the extra facial portion of the gland without inflammatory behaviour (n = 91) had 4.4% facial nerve temporary weakness rate and no permanent palsy. The combined use of the operative microscope and intraoperative nerve monitoring seems to guarantee facial nerve preservation during parotidectomy. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.

[Physiology of the urethral sphincteric vesico-prostatic complex].

PubMed

Carmignani, L; Gadda, F; Dell'Orto, P; Ferruti, M; Grisotto, M; Rocco, F

2001-09-01

We propose a review of the literature about innervation and physiology of the urethral sphincteric complex. Parasympathetic innervation of the pelvic viscera comes from ventral branches of the sacral nerves (S2-S4). The orthosympathetic component derives from superior hypogastric plexus and runs down the hypogastric nerves to form the right and left pelvic plexus together with the parasympathetic component. The pelvic plexus is situated inferolaterally with respect to the rectum and runs on the surface of the levator ani muscle down to the prostatic apex. The pelvic plexus gives innervation to the rectum, the bladder, the prostate and the urethral sphincteric complex. The pelvic muscular floor is innervated by the somatic component (pudendal nerve) derived from the sacral branches (S2-S4). Bladder neck and smooth muscle urethral sphincter innervation is given mostly by the orthosympathetic component. The rhabdosphincter innervation comes from the pudendal nerve and from the pelvic plexus; its role in the continence mechanism is probably to give steady tonic urethral compression. Levator ani muscle takes part in the sphincteric complex with its anteromedial pubococcygeal portion. It plays its role strengthening the sphincteric tone during increase of the abdominal pressure or during active quick stop cessation of the urinary stream.

Neoadjuvant denosumab for the treatment of a sacral osteoblastoma.

PubMed

Reynolds, Jeremy J; Rothenfluh, Dominique A; Athanasou, Nick; Wilson, Shaun; Kieser, David C

2018-01-22

To present a case of aggressive sacral osteoblastoma (OB) treated with neoadjuvant denosumab therapy and en bloc resection. Case report of a 14-year-old male with an aggressive OB affecting the superior articular process of the left first sacral segment. The lesion was lytic and metabolically active and involved the left-sided posterior elements of S1-S3 with extension into the spinal canal, affecting the left S1, S2, S3, S4 and S5 nerve roots. He was treated for 1 month with neoadjuvant denosumab followed by en bloc resection. Denosumab therapy caused regression of the tumour and converted the diffuse infiltrative mass into a well-defined solid (osteoma-like) structure, aiding surgical resection and preserving the S1, S4 and S5 nerve roots. Histologically, the treated lesion showed abundant sclerotic woven bone and osteoblasts with absence of osteoclasts. A short course of denosumab caused tumour regression, ossification and conversion of an aggressive OB into a sclerotic, well-defined lesion thus aiding surgical resection and preservation of neural structures. Neoadjuvant therapy reduced osteoclast numbers but PET showed that the lesion remained FDG avid post-therapy.

Morphological changes in neurons of the hind limb reflex arc during long term immobilization

NASA Technical Reports Server (NTRS)

Tkachenko, Z. Y.

1980-01-01

Twelve adult rabbits were immobilized for 9 to 31 days, followed by histological study of the nerve processes of lumbar vertebra 7 and sacral vertebra 1, the sciatic nerve and the motor endings of the thigh muscles. In the spinal ganglia, dystrophic changes of increasing severity with immobilization time were found, including pericellular edema, vacuolized neuroplasm, pycnotic changes, cytolysis and destruction. Chromatophilic matter decreased and was partly bleached, and amitotic division occurred. A portion of the sciatic nerve fibers were argentophilic, and some fragmentary decomposition occurred. Considerable dystrophic changes occurred in the motor nerve endings.

Finding sacral: Developmental evolution of the axial skeleton of odontocetes (Cetacea).

PubMed

Buchholtz, Emily A; Gee, Jessica K

2017-07-01

Axial morphology was dramatically transformed during the transition from terrestrial to aquatic environments by archaeocete cetaceans, and again during the subsequent odontocete radiation. Here, we reconstruct the sequence of developmental events that underlie these phenotypic transitions. Archaeocete innovations include the loss of primaxial/abaxial interaction at the sacral/pelvic articulation and the modular dissociation of the fluke from the remainder of the tail. Odontocetes subsequently integrated lumbar, sacral, and anterior caudal vertebrae into a single torso module, and underwent multiple series-specific changes in vertebral count. The conservation of regional proportions despite regional fluctuations in count strongly argues that rates of somitogenesis can vary along the column and that segmentation was dissociated from regionalization during odontocete evolution. Conserved regional proportions also allow the prediction of the location and count of sacral homologs within the torso module. These predictions are tested with the analysis of comparative pudendal nerve root location and geometric morphometrics. We conclude that the proportion of the column represented by the sacral series has been conserved, and that its vertebrae have changed in count and relative centrum length in parallel with other torso vertebrae. Although the sacral series of odontocetes is de-differentiated, it is not de-regionalized. © 2017 Wiley Periodicals, Inc.

Herpes zoster producing temporary erectile dysfunction.

PubMed

Rix, G H; Carroll, D N; MacFarlane, J R

2001-12-01

Varicella Zoster affecting the sacral dermatomes is a rare but well recognised cause of urinary retention. Only one case of erectile dysfunction associated with Varicella Zoster has previously been described, which was longstanding, but no cases of transient erectile dysfunction following Zoster infection are recorded. We present one such case.

Water-cooled radiofrequency neuroablation for sacroiliac joint dysfunctional pain

PubMed Central

Biswas, Binay Kumar; Dey, Samarjit; Biswas, Saumya; Mohan, Varinder Kumar

2016-01-01

Sacroiliac (SI) joint dysfunction is a common source of chronic low-back pain. Recent evidences from different parts of the world suggest that cooled radiofrequency (RF) neuroablation of sacral nerves supplying SI joints has superior pain alleviating properties than available existing treatment options for SI joint dysfunctional pain. A 35-year-old male had intractable bilateral SI joint pain (numeric rating scale [NRS] – 9/10) with poor treatment response to intra-articular steroid therapy. Bilateral water cooled = RF was applied for neuroablation of nerves supplying both SI joints. Postprocedure pain intensity was 5/10 and after 7 days it was 2/10. On 18th-month follow-up, he is pain free except for mild pain (NRS 2/10) on occasional extreme twisting of the back. This case attempts to highlight that sacral neuroablation based on cooled RF technique can be a long lasting remedial option for chronic SI joint pain unresponsive to conventional treatment. PMID:28096589

Water-cooled radiofrequency neuroablation for sacroiliac joint dysfunctional pain.

PubMed

Biswas, Binay Kumar; Dey, Samarjit; Biswas, Saumya; Mohan, Varinder Kumar

2016-01-01

Sacroiliac (SI) joint dysfunction is a common source of chronic low-back pain. Recent evidences from different parts of the world suggest that cooled radiofrequency (RF) neuroablation of sacral nerves supplying SI joints has superior pain alleviating properties than available existing treatment options for SI joint dysfunctional pain. A 35-year-old male had intractable bilateral SI joint pain (numeric rating scale [NRS] - 9/10) with poor treatment response to intra-articular steroid therapy. Bilateral water cooled = RF was applied for neuroablation of nerves supplying both SI joints. Postprocedure pain intensity was 5/10 and after 7 days it was 2/10. On 18 th -month follow-up, he is pain free except for mild pain (NRS 2/10) on occasional extreme twisting of the back. This case attempts to highlight that sacral neuroablation based on cooled RF technique can be a long lasting remedial option for chronic SI joint pain unresponsive to conventional treatment.

Progressive dysautonomia in two patients with xeroderma pigmentosum group A.

PubMed

Kobayashi, Osamu; Miyahara, Hiroaki; Abe, Naho; Goto, Chika; Okanari, Kazuo; Akiyoshi, Kensuke; Korematsu, Seigo; Izumi, Tatsuro

2014-06-01

Xeroderma pigmentosum group A (XPA) is a rare autosomal-recessive disorder caused by a defect in nucleotide excision repair. Progressive dysautonomia in patients with XPA is rarely described. Two juvenile male patients with XPA suffered from dysphagia, sleep interruption, and dysuria from the age of 10 to 19 years, successively. These autonomic symptoms might have been caused by progressive descending degeneration of cranial nerves IX and X and the sacral parasympathetic nerve, including Onuf's nucleus. One patient died from sudden cardiopulmonary arrest during postural change and tracheal suction. Heart rate variability analyses of these patients revealed parasympathetic dysautonomia, based on decreased high-frequency values. The insidiously progressive dysautonomia in these two patients with XPA suggested progressive descending degeneration extending from the medulla oblongata to the sacral spinal cord, which is an ominous sign of end-stage disease and a risk factor of sudden death attributable to XPA. Copyright © 2014 Elsevier Inc. All rights reserved.

Neuromodulation for the Treatment of Lower Urinary Tract Symptoms.

PubMed

Yamanishi, Tomonori; Kaga, Kanya; Fuse, Miki; Shibata, Chiharu; Uchiyama, Tomoyuki

2015-09-01

Neuromodulation therapy incorporates electrical stimulation to target specific nerves that control lower urinary tract symptoms (LUTS). The objectives of this article are to review the mechanism of action, the type of neuromodulation, and the efficacy of neuromodulation mainly according to the results of randomized controlled trials. Neuromodulation includes pelvic floor electrical stimulation (ES) using vaginal, anal and surface electrodes, interferential therapy (IF), magnetic stimulation (MS), percutaneous tibial nerve stimulation, and sacral nerve stimulation (SNS). The former four stimulations are used for external periodic (short-term) stimulation, and SNS are used for internal, chronic (long-term) stimulation. All of these therapies have been reported to be effective for overactive bladder or urgency urinary incontinence. Pelvic floor ES, IF, and MS have also been reported to be effective for stress urinary incontinence. The mechanism of neuromodulation for overactive bladder has been reported to be the reflex inhibition of detrusor contraction by the activation of afferent fibers by three actions, i.e., the activation of hypogastric nerve, the direct inhibition of the pelvic nerve within the sacral cord and the supraspinal inhibition of the detrusor reflex. The mechanism of neuromodulation for stress incontinence is contraction of the pelvic floor muscles through an effect on the muscle fibers as well as through the stimulation of pudendal nerves. Overall, cure and improvement rates of these therapies for urinary incontinence are 30-50, and 60-90% respectively. MS has been considered to be a technique for stimulating nervous system noninvasively. SNS is indicated for patients with refractory overactive bladder and urinary retention. © 2015 Wiley Publishing Asia Pty Ltd.

Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders.

PubMed

Bharucha, Adil E; Rao, Satish S C; Shin, Andrea S

2017-12-01

The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders. Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

Assessment of recurrent laryngeal nerve function during thyroid surgery

PubMed Central

Douglas, J; Smith, B; Dougherty, T; Ayshford, C

2014-01-01

Introduction There is disparity in the reported incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy following thyroidectomy. Much of the disparity is due to the method of assessing vocal cord function. We sought to identify the incidence and natural history of temporary and permanent vocal cord palsy following thyroid surgery. The authors wanted to establish whether intraoperative nerve monitoring and stimulation aids in prognosis when managing vocal cord palsy. Methods Prospective data on consecutive thyroid operations were collected. Intraoperative nerve monitoring and stimulation, using an endotracheal tube mounted device, was performed in all cases. Endoscopic examination of the larynx was performed on the first postoperative day and at three weeks. Results Data on 102 patients and 123 nerves were collated. Temporary and permanent RLN palsy rates were 6.1% and 1.7%. Most RLN palsies were identified on the first postoperative day with all recognised at the three-week review. No preoperative clinical risk factors were identified. Although dysphonia at the three-week follow-up visit was the only significant predictor of vocal cord palsy, only two-thirds of patients with cord palsies were dysphonic. Intraoperative nerve monitoring and stimulation did not predict outcome in terms of vocal cord function. Conclusions Temporary nerve palsy rates were consistent with other series where direct laryngoscopy is used to assess laryngeal function. Direct laryngoscopy is the only reliable measure of cord function, with intraoperative monitoring being neither a reliable predictor of cord function nor a predictor of eventual laryngeal function. The fact that all temporary palsies recovered within four months has implications for staged procedures. PMID:24780671

Assessment of recurrent laryngeal nerve function during thyroid surgery.

PubMed

Smith, J; Douglas, J; Smith, B; Dougherty, T; Ayshford, C

2014-03-01

There is disparity in the reported incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy following thyroidectomy. Much of the disparity is due to the method of assessing vocal cord function. We sought to identify the incidence and natural history of temporary and permanent vocal cord palsy following thyroid surgery. The authors wanted to establish whether intraoperative nerve monitoring and stimulation aids in prognosis when managing vocal cord palsy. Prospective data on consecutive thyroid operations were collected. Intraoperative nerve monitoring and stimulation, using an endotracheal tube mounted device, was performed in all cases. Endoscopic examination of the larynx was performed on the first postoperative day and at three weeks. Data on 102 patients and 123 nerves were collated. Temporary and permanent RLN palsy rates were 6.1% and 1.7%. Most RLN palsies were identified on the first postoperative day with all recognised at the three-week review. No preoperative clinical risk factors were identified. Although dysphonia at the three-week follow-up visit was the only significant predictor of vocal cord palsy, only two-thirds of patients with cord palsies were dysphonic. Intraoperative nerve monitoring and stimulation did not predict outcome in terms of vocal cord function. Temporary nerve palsy rates were consistent with other series where direct laryngoscopy is used to assess laryngeal function. Direct laryngoscopy is the only reliable measure of cord function, with intraoperative monitoring being neither a reliable predictor of cord function nor a predictor of eventual laryngeal function. The fact that all temporary palsies recovered within four months has implications for staged procedures.

Surgical anesthesia with a combination of T12 paravertebral block and lumbar plexus, sacral plexus block for hip replacement in ankylosing spondylitis: CARE-compliant 4 case reports.

PubMed

Ke, Xijian; Li, Ji; Liu, Yong; Wu, Xi; Mei, Wei

2017-06-26

Anesthesia management for patients with severe ankylosing spondylitis scheduled for total hip arthroplasty is challenging due to a potential difficult airway and difficult neuraxial block. We report 4 cases with ankylosing spondylitis successfully managed with a combination of lumbar plexus, sacral plexus and T12 paravertebral block. Four patients were scheduled for total hip arthroplasty. All of them were diagnosed as severe ankylosing spondylitis with rigidity and immobilization of cervical and lumbar spine and hip joints. A combination of T12 paravertebral block, lumbar plexus and sacral plexus block was successfully used for the surgery without any additional intravenous anesthetic or local anesthetics infiltration to the incision, and none of the patients complained of discomfort during the operations. The combination of T12 paravertebral block, lumbar plexus and sacral plexus block, which may block all nerves innervating the articular capsule, surrounding muscles and the skin involved in total hip arthroplasty, might be a promising alternative for total hip arthroplasty in ankylosing spondylitis.

Sacral neuromodulation for lower urinary tract dysfunction.

PubMed

Van Kerrebroeck, Philip E V; Marcelissen, Tom A T

2012-08-01

To review the technique, indications, results and working mechanisms of sacral neuromodulation (SNM) for lower urinary tract dysfunction. The available literature on SNM for lower urinary tract dysfunction was searched. Based on the information available in the literature and also based on personal experience, the urological indications, technique, mechanisms of action and results of SNM are presented and discussed. SNM for lower urinary tract dysfunction involves stimulation of the 3rd sacral nerve with an electrode implanted in the sacral foramen and connected to a pulse generator. The technique is accepted by the FDA since 1997. Currently, SNM for lower urinary tract dysfunction has been successfully used in about 26,000 patients with various forms of lower urinary tract dysfunction, including urgency, frequency and urgency incontinence as well as non-obstructive urinary retention. The actual procedure of SNM consists of a minimal invasive technique and is effective in about 70% of the patients who have been implanted with a permanent system. Also, in pelvic pain, interesting results have been described. SNM modulates the micturition reflexes at different levels in the central nervous system. Sacral neuromodulation is a safe and effective therapy for various forms of lower urinary tract dysfunction, including urgency, frequency and urgency incontinence as well as non-obstructive urinary retention. It should be the first choice after failure of maximal conservative therapy.

Increased yield pressure in the anal canal during sacral nerve stimulation: a pilot study with the functional lumen imaging probe.

PubMed

Haas, S; Liao, D; Gregersen, H; Lundby, L; Laurberg, S; Krogh, K

2017-02-01

Sacral nerve stimulation (SNS) is a well-established treatment for fecal incontinence but its mode of action remains obscure. Anal sphincter function is usually evaluated with manometry but resistance to distension may be a more appropriate parameter than luminal pressure. The functional lumen imaging probe allows detailed description of distension properties of the anal canal. Our objective in this study was to characterize the impact of SNS on distension properties of the anal canal in patients with idiopathic fecal incontinence. We studied 10 women (median age 64 [44-79] years) with idiopathic fecal incontinence at baseline and during SNS. The luminal geometry of the anal canal was examined with the FLIP at rest and during squeeze and the distensibility of the anal canal was investigated during filling of the bag. All patients were successfully treated with SNS and the mean Wexner Incontinence Score was reduced from 14.9 ± 4 to 7.1 ± 4.8 (P<.001). The pressure required to open the narrowest point of the anal canal during distension (yield pressure) increased from 14.5 ± 12.2 mmHg at baseline to 20.5 ± 13.3 mmHg during SNS (P<.01). The pressure-strain elastic modulus increased non-significantly from 2.2 ± 0.5 to 2.9 ± 1.6 kPa, indicating increased stiffness of the anal canal. The yield pressure and the resistance to distension increased in response to SNS for idiopathic fecal incontinence. This will inevitably increase the resistance to flow through the anal canal, which may contribute to the benefits of sacral nerve stimulation. © 2016 John Wiley & Sons Ltd.

Evaluation of Partial Cut-out of Sacroiliac Screws From the Sacral Ala Slope via Pelvic Inlet and Outlet View.

PubMed

Zhang, Jingwei; Hamilton, Ryan; Li, Ming; Ebraheim, Nabil A; He, Xianfeng; Liu, Jiayong; Zhu, Limei

2015-12-01

An anatomic and radiographic study of placement of sacroiliac screws. The aim of this study was to quantitatively assess the risk of partial cut-out of sacroiliac screws from the sacral ala slope via inlet and outlet view. The partial cut-out of sacroiliac screws from the superior surface of sacral ala can jeopardize the L5 nerve root, which is difficult to identify on the pelvic inlet and outlet views. Computed tomography images of 60 patients without pelvic ring deformity or injury were used to measure the width (on inlet view) and height (on outlet view) of the sacral ala. The angle of the sacral ala slope was measured on lateral view. According to the measured parameters, the theoretical safe trajectories of screw placement were calculated using inverse trigonometric functions. Under fluoroscopic guidance, a sacroiliac screw was placed close to the midline on both inlet and outlet views, including posterosuperior, posteroinferior, anterosuperior, and anteroinferior regions to the midline. The incidence of screw partial cut-out from the superior surface of sacral ala was identified. The measured widths and heights of the sacral alas were 28.1 ± 2.8 and 29.8 ± 3.1 mm, respectively. The average angle between the superior aspect of the S1 vertebral body and the superior aspect of the sacral ala was 37.2 ± 2.5 degrees. The rate of partial cut-out of the screws from the superior surface of sacral ala slope was 12.5% (5/40) in posterosuperior, 0% (0/40) in posteroinferior, 70% (28/40) in anterosuperior, and 20% (8/40) in anteroinferior. To avoid the risk of partial cut-out from sacroiliac screw placement, more precise description should be added to the conventional description: the sacroiliac screws should be placed at the inferior half portion on outlet view and at the posterior half portion on inlet view. 4.

[Effect of iliolumbar fixation in patients with Tile C pelvic injury and analysis of relative factors].

PubMed

Ge, Zhenxin; Wang, Ben; Zhang, Dongzheng; Liu, Zhaojie; Zhang, Yinguang; Jia, Jian

2012-11-01

To explore the relative prognostic factors of Tile C pelvic injury after iliolumbar fixation. Between March 2007 and March 2010, 60 patients with Tile C pelvic injuries were surgically treated with iliolumbar fixation, including 39 males and 21 females with an average age of 37 years (range, 17-66 years). Of them, 27 cases were classified as Tile C1, 20 as Tile C2, and 13 as Tile C3. The preoperative injury severity score (ISS) was 12-66 (mean, 29.4). The time from injury to surgery was 2-25 days (mean, 8.1 days). Iliolumbar fixation was performed in all patients. Unconditional logistic analysis was used to analyze the relationship between the age, sex, body mass index (BMI), operation opportunity, the preoperative combined injury, classification of fracture, the postoperative complication, reduction outcome, sacral nerve injury, and the time of physical exercise and the prognosis. All 60 patients were followed up 12-56 months (mean, 27.3 months). Infection of incisions occurred in 12 cases and were cured after dressing change; healing of incision by first intention was obtained in the other patients. Delay sacral nerve injury was found in 15 patients, 6 patients underwent nerve decompression, and 9 underwent conservative treatment. Ten patients had nail protrusion of Schanz screws at the posterior superior illac spine, and 3 patients had pain, which was relieved after removal of the internal fixator. One patient had bone-grafting nonunion of sacroiliac joint, which was improved by pressured bone graft. Five patients had the beam breakage without significant effect. Six patients had deep vein thrombosis, among them 4 underwent filter and 2 underwent nonsurgical treatment. The healing time of fracture was 3-6 months (mean, 3.9 months). According to the Matta function score, the results were excellent in 31 cases, good in 24 cases, fair in 3 cases, and poor in 2 cases with an excellent and good rate of 91.7% at last follow-up. Majeed score was 58-100 (mean, 86), 28 were rated as excellent, 12 as good, 16 as fair, and 4 as poor with an excellent and good rate of 66.7%. The logistic analysis showed that the age, sex, BMI, and postoperative complications were not prognostic factors; early operation (within 10 days), early function exercises (within 7 days), the better reduction quality, and the less sacral nerve injury were in favor of prognosis; and the worse preoperative combined injury and pelvic injury were, the worse the prognosis was. Operation opportunity, the preoperative combined injury, reduction outcome, sacral nerve injury, and the time of physical exercise are all significantly prognostic factors of Tile C pelvic injuries.

Neuromodulation: urodynamic effects of sacral (S3) spinal nerve stimulation in patients with detrusor instability or detrusor hyperflexia.

PubMed

Bosch, J L; Groen, J

1998-05-01

The aim of this study was to determine the urodynamic effects of sacral (S3) nerve stimulation in patients with urge incontinence due to detrusor overactivity which has been refractory to conservative treatment. A total of 24 patients with idiopathic detrusor instability and five with neurogenic hyperreflexia were studied urodynamically before and 6 months after a permanent S3 foramen electrode implant. The urodynamic studies at follow-up were done with the stimulus on. Clinically, the average voiding frequency, the number of leakage episodes and pad use per 24 h decreased significantly. Improvement in several urodynamic parameters was noted. In the idiopathic as well as in the neurogenic group, the correlation between symptomatic and urodynamic improvement was incomplete. Neuromodulation leads to improvement of several urodynamic parameters in patients with urge incontinence due to detrusor overactivity which has been refractory to conservative treatment and appears to be a valuable treatment option in these patients.

Percutaneous tibial nerve stimulation vs sacral nerve stimulation for faecal incontinence: a comparative case-matched study.

PubMed

Al Asari, S; Meurette, G; Mantoo, S; Kubis, C; Wyart, V; Lehur, P-A

2014-11-01

The study assessed the initial experience with posterior tibial nerve stimulation (PTNS) for faecal incontinence and compared it with sacral nerve stimulation (SNS) performed in a single centre during the same timespan. A retrospective review of a prospectively collected database was conducted at the colorectal unit, University Hospital, Nantes, France, from May 2009 to December 2010. Seventy-eight patients diagnosed with chronic severe faecal incontinence underwent neurostimulation including PTNS in 21 and SNS in 57. The main outcome measures were faecal incontinence (Wexner score) and quality of life (Fecal Incontinence Quality of Life, FIQL) scores in a short-term follow-up. No significant differences were observed in patients' characteristics. Of 57 patients having SNS, 18 (32%) failed peripheral nerve evaluation and 39 (68%) received a permanent implant. Two (5%) developed a wound infection. No adverse effects were recorded in the PTNS group. There was no significant difference in the mean Wexner and FIQL scores between patients having PTNS and SNS at 6 (P = 0.39 and 0.09) and 12 months (P = 0.79 and 0.37). A 50% or more improvement in Wexner score was seen at 6 and 12 months in 47% and 30% of PTNS patients and in 50% and 58% of SNS patients with no significant difference between the groups. Posterior tibial nerve stimulation is a valid method of treating faecal incontinence in the short term when conservative treatment has failed. It is easier, simpler, cheaper and less invasive than SNS with a similar short-term outcome. Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.

Differentiation between Symptomatic and Asymptomatic Extraforaminal Stenosis in Lumbosacral Transitional Vertebra: Role of Three-Dimensional Magnetic Resonance Lumbosacral Radiculography

PubMed Central

Kim, Jae Woon; Lee, Jae Kyo

2012-01-01

Objective To investigate the role of lumbosacral radiculography using 3-dimentional (3D) magnetic resonance (MR) rendering for diagnostic information of symptomatic extraforaminal stenosis in lumbosacral transitional vertebra. Materials and Methods The study population consisted of 18 patients with symptomatic (n = 10) and asymptomatic extraforaminal stenosis (n = 8) in lumbosacral transitional vertebra. Each patient underwent 3D coronal fast-field echo sequences with selective water excitation using the principles of the selective excitation technique (Proset imaging). Morphologic changes of the L5 nerve roots at the symptomatic and asymptomatic extraforaminal stenosis were evaluated on 3D MR rendered images of the lumbosacral spine. Results Ten cases with symptomatic extraforaminal stenosis showed hyperplasia and degenerative osteophytes of the sacral ala and/or osteophytes at the lateral margin of the L5 body. On 3D MR lumbosacral radiculography, indentation of the L5 nerve roots was found in two cases, while swelling of the nerve roots was seen in eight cases at the exiting nerve root. Eight cases with asymptomatic extraforaminal stenosis showed hyperplasia and degenerative osteophytes of the sacral ala and/or osteophytes at the lateral margin of the L5 body. Based on 3D MR lumbosacral radiculography, indentation or swelling of the L5 nerve roots was not found in any cases with asymptomatic extraforaminal stenosis. Conclusion Results from 3D MR lumbosacral radiculography Indicate the indentation or swelling of the L5 nerve root in symptomatic extraforaminal stenosis. Based on these findings, 3D MR radiculography may be helpful in the diagnosis of the symptomatic extraforaminal stenosis with lumbosacral transitional vertebra. PMID:22778561

[Primary genital herpes with sacral meningoradiculitis].

PubMed

Carron, P-N; Anguenot, J-L; Dubuisson, J-B

2004-02-01

Herpetic genital infection is a common sexually transmitted disease, caused in most cases by type 2 Herpes simplex virus (HSV2). This virus is characterized by its neurotropic properties and its ability to establish latency in sacral sensory ganglions. Some cases of genital primo-infection are complicated by viral replication dissemination to neigbhoring nerve structures like meninges and radicular terminations. In such cases muco-cutaneous manifestations are associated with peripheral neurological impairment in the form of meningo-radiculitis. Physicians should be familiar with these neurological symptoms knowing that they always regress completely. The present report illustrates these complications and reviews the potential neurological implications described in the literature.

Temporary Blindness after Inferior Alveolar Nerve Block.

PubMed

Barodiya, Animesh; Thukral, Rishi; Agrawal, Shaila Mahendra; Rai, Anshul; Singh, Siddharth

2017-03-01

Inferior Alveolar Nerve Block (IANB) anaesthesia is one of the common procedures in dental clinic. This procedure is safe, but complications may still occur. Ocular complications such as diplopia, loss of vision, or ophthalmoplegia are extremely rare. This case report explains an event where due to individual anatomic variation of the sympathetic vasoconstrictor nerve and maxillary and middle meningeal arteries, intravascular administration of anaesthetic agent caused unusual ocular signs and symptoms such as temporary blindness.

Role of motor-evoked potential monitoring in conjunction with temporary clipping of spinal nerve roots in posterior thoracic spine tumor surgery.

PubMed

Eleraky, Mohammed A; Setzer, Matthias; Papanastassiou, Ioannis D; Baaj, Ali A; Tran, Nam D; Katsares, Kiesha M; Vrionis, Frank D

2010-05-01

The vascular supply of the thoracic spinal cord depends on the thoracolumbar segmental arteries. Because of the small size and ventral course of these arteries in relation to the dorsal root ganglion and ventral root, they cannot be reliably identified during surgery by anatomic or morphologic criteria. Sacrificing them will most likely result in paraplegia. The goal of this study was to evaluate a novel method of intraoperative testing of a nerve root's contribution to the blood supply of the thoracic spinal cord. This is a clinical retrospective study of 49 patients diagnosed with thoracic spine tumors. Temporary nerve root clipping combined with motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring was performed; additionally, postoperative clinical evaluation was done and reported in all cases. All cases were monitored by SSEP and MEPs. The nerve root to be sacrificed was temporarily clipped using standard aneurysm clips, and SSEP/MEP were assessed before and after clipping. Four nerve roots were sacrificed in four cases, three nerve roots in eight cases, and two nerve roots in 22 cases. Nerve roots were sacrificed bilaterally in 12 cases. Most patients (47/49) had no changes in MEP/SSEP and had no neurological deficit postoperatively. One case of a spinal sarcoma demonstrated changes in MEP after temporary clipping of the left T11 nerve root. The nerve was not sacrificed, and the patient was neurologically intact after surgery. In another case of a sarcoma, MEPs changed in the lower limbs after ligation of left T9 nerve root. It was felt that it was a global event because of anesthesia. Postoperatively, the patient had complete paraplegia but recovered almost completely after 6 months. Temporary nerve root clipping combined with MEP and SSEP monitoring may enhance the impact of neuromonitoring in the intraoperative management of patients with thoracic spine tumors and favorably influence neurological outcome. Copyright 2010 Elsevier Inc. All rights reserved.

Spastic long-lasting reflexes in the awake rat after sacral spinal cord injury.

PubMed

Bennett, D J; Sanelli, L; Cooke, C L; Harvey, P J; Gorassini, M A

2004-05-01

Following chronic sacral spinal cord transection in rats the affected tail muscles exhibit marked spasticity, with characteristic long-lasting tail spasms evoked by mild stimulation. The purpose of the present paper was to characterize the long-lasting reflex seen in tail muscles in response to electrical stimulation of the tail nerves in the awake spastic rat, including its development with time and relation to spasticity. Before and after sacral spinal transection, surface electrodes were placed on the tail for electrical stimulation of the caudal nerve trunk (mixed nerve) and for recording EMG from segmental tail muscles. In normal and acute spinal rats caudal nerve trunk stimulation evoked little or no EMG reflex. By 2 wk after injury, the same stimulation evoked long-lasting reflexes that were 1) very low threshold, 2) evoked from rest without prior EMG activity, 3) of polysynaptic latency with >6 ms central delay, 4) about 2 s long, and 5) enhanced by repeated stimulation (windup). These reflexes produced powerful whole tail contractions (spasms) and developed gradually over the weeks after the injury (< or =52 wk tested), in close parallel to the development of spasticity. Pure low-threshold cutaneous stimulation, from electrical stimulation of the tip of the tail, also evoked long-lasting spastic reflexes, not seen in acute spinal or normal rats. In acute spinal rats a strong C-fiber stimulation of the tip of the tail (20 x T) could evoke a weak EMG response lasting about 1 s. Interestingly, when this C-fiber stimulation was used as a conditioning stimulation to depolarize the motoneuron pool in acute spinal rats, a subsequent low-threshold stimulation of the caudal nerve trunk evoked a 300-500 ms long reflex, similar to the onset of the long-lasting reflex in chronic spinal rats. A similar conditioned reflex was not seen in normal rats. Thus there is an unusually long low-threshold polysynaptic input to the motoneurons (pEPSP) that is normally inhibited by descending control. This pEPSP is released from inhibition immediately after injury but does not produce a long-lasting reflex because of a lack of motoneuron excitability. With chronic injury the motoneuron excitability is increased markedly, and the pEPSP then triggers sustained motoneuron discharges associated with long-lasting reflexes and muscle spasms.

A novel technique to identify the nerve of origin in head and neck schwannomas.

PubMed

Ching, H H; Spinner, A G; Reeve, N H; Wang, R C

2018-04-18

Identifying the nerve of origin in head and neck schwannomas is a diagnostic challenge. Surgical management leads to a risk of permanent deficit. Accurate identification of the nerve would improve operative planning and patient counselling. Three patients with head and neck schwannomas underwent a diagnostic procedure hypothesised to identify the nerve of origin. The masses were infiltrated with 1 per cent lidocaine solution, and the patients were observed for neurological deficits. All three patients experienced temporary loss of nerve function after lidocaine injection. Facial nerve palsy, voice changes with documented unilateral same-side vocal fold paralysis, and numbness in the distribution of the maxillary nerve (V2), respectively, led to a likely identification of the nerve of origin. Injection of lidocaine into a schwannoma is a safe, in-office procedure that produces a temporary nerve deficit, which may enable accurate identification of the nerve of origin of a schwannoma. Identifying the nerve of origin enhances operative planning and patient counselling.

Retention of urine in anogenital herpetic infection.

PubMed

Oates, J K; Greenhouse, P R

1978-04-01

In 17 patients, 15 women and 2 men, acute retention of urine developed in association with an attack of anogenital herpes. Constipation, blunting of sensation over the 2nd and 3rd sacral dermatomes, and neuralgic pains in the same area (with absence of the bulbocavernosus reflex in some individuals) suggested localised lumbosacral meningomyelitis with involvement of mainly sacral-nerve roots. The urinary dysfunction persisted on average for ten days and in 4 patients was severe enough to warrant catheterisation. Anogenital herpes should always be considered as a possible cause of acute retention of urine in sexually active young people and the possibility of occult herpetic infection of the cervix and rectum should be investigated.

Sacral nerve stimulation for neuromodulation of the lower urinary tract.

PubMed

Hubsher, Chad P; Jansen, Robert; Riggs, Dale R; Jackson, Barbara J; Zaslau, Stanley

2012-10-01

Sacral neuromodulation (SNM) has become a standard treatment option for patients suffering from urinary urge incontinence, urgency-frequency, and/or nonobstructive urinary retention refractory to conservative and pharmacologic treatment. Since its initial development, the manufacturer of InterStim therapy (Medtronic, Inc., Minneapolis, MN, USA), has introduced technical modifications, while surgeons and researchers have adapted and published various innovations and alterations of the implantation technique. In this article, we feature our SNM technique including patient selection, comprehensive dialogue/evaluation, procedure details, and appropriate follow up. Although there is often great variability in patients with lower urinary tract dysfunction, we maintain that great success can be achieved with a systematic and methodical approach to SNM.

Nerve Blocks

MedlinePlus

... turn off" a pain signal along a specific distribution of nerve. Imaging guidance may be used to place the needle in the most appropriate location for maximum benefit. A nerve block may allow a damaged nerve time to heal, provide temporary pain relief and help ...

Sciatica caused by lumbar epidural gas.

PubMed

Belfquih, Hatim; El Mostarchid, Brahim; Akhaddar, Ali; gazzaz, Miloudi; Boucetta, Mohammed

2014-01-01

Gas production as a part of disc degeneration can occur but rarely causes nerve compression syndromes. The clinical features are similar to those of common sciatica. CT is very useful in the detection of epidural gas accumulation and nerve root compression. We report a case of symptomatic epidural gas accumulation originating from vacuum phenomenon in the intervertebral disc, causing lumbo-sacral radiculopathy. A 45-year-old woman suffered from sciatica for 9 months. The condition worsened in recent days. Computed tomography (CT) demonstrated intradiscal vacuum phenomenon, and accumulation of gas in the lumbar epidural space compressing the dural sac and S1 nerve root. After evacuation of the gas, her pain resolved without recurrence.

Subarachnoid and basal cistern navigation through the sacral hiatus with guide wire assistance.

PubMed

Layer, Lauren; Riascos, Roy; Firouzbakht, Farhood; Amole, Adewumi; Von Ritschl, Rudiger; Dipatre, Pier; Cuellar, Hugo

2011-07-01

Intraspinal navigation with catheters and fiberscopes has shown feasible results for diagnosis and treatment of intraspinal and intracranial lesions. The most common approach, lumbar puncture, has allowed access to the spinal cord, however, coming with the difficulties of fiberscope damage and decreased torque for guidance. Our objective in this study is to allow an alternate access, the sacral hiatus, with guide wire assistance into the subarachnoid and intracranial structures, while easing the angle of entry and increasing torque. We advanced catheters with guide wire and fluoroscopy assistance into the sacral hiatus of three cadavers. After entry, the thecal sac was punctured and the catheter with guide wire was advanced rostrally until positioned in the basal cisterns of the brain. We confirmed catheter placement with contrast injection, autopsy, and dissection. In our study, the sacral hiatus was easily accessed, but resistance was found when attempting to puncture the thecal sac. The advancement of the catheter with guide wire assistance glided easily rostrally until some mild resistance was discovered at entry into the foramen magnum. With redirection, all catheters passed with ease into the basal cisterns. Positioning was confirmed with contrast injection with fluoroscopy evidence, autopsy, and dissection. There was no macroscopic or microscopic evidence of damage to the spinal roots, spinal cord, or cranial nerves. The sacral hiatus with guide wire assistance is an accessible conduit for uncomplicated entry into the subarachnoid and basal cistern space without damaging surrounding structures.

Close correlation of herpes zoster-induced voiding dysfunction with severity of zoster-related pain: A single faculty retrospective study.

PubMed

Fujii, Mizue; Takahashi, Ichiro; Honma, Masaru; Ishida-Yamamoto, Akemi

2015-11-01

Herpes zoster (HZ), a common vesiculo-erythematous skin disease associated with reactivation of varicella zoster virus in the cranial nerve, dorsal root, and autonomic ganglia, is accompanied by several related symptoms represented by postherpetic neuralgia. Among them, involvement of vesicorectal dysfunction is relatively rare. The vesicorectal symptom can usually be recovered in transient course, but is quite important in terms of impaired quality of life. Male individuals affected with HZ and skin lesions on sacral dermatome have been reported as independent risk factors of zoster-related voiding dysfunction. In this study, urinary symptoms were focused upon and six patients with zoster-related voiding dysfunction at a single faculty of dermatology in Japan from 2009 to 2014 were retrospectively analyzed. All patients showed HZ lesions on the sacral area and the urinary symptom recovered in approximately 2 months (14 days to 7 months). The term of treatment for zoster-associated urinary dysfunction was positively correlated with that for zoster-related pain without significance (r = 0.661, P = 0.153). Average treatment term for pain relief of sacral HZ accompanied by voiding dysfunction (91.3 ± 76.44 days) was significantly longer than that of sacral HZ without urinary symptom (18.9 ± 20.42 days) (P = 0.032). These results suggested that zoster-related voiding dysfunction would mainly be involved in sacral HZ and closely associated with severity of zoster-related pain. Dermatologists should be aware that severe zoster-related pain accompanied by sacral HZ, which is related to prolonged treatment of pain relief, can be a predictive factor of voiding dysfunction. © 2015 Japanese Dermatological Association.

Navigation-aided visualization of lumbosacral nerves for anterior sacroiliac plate fixation: a case report.

PubMed

Takao, Masaki; Nishii, Takashi; Sakai, Takashi; Sugano, Nobuhiko

2014-06-01

Anterior sacroiliac joint plate fixation for unstable pelvic ring fractures avoids soft tissue problems in the buttocks; however, the lumbosacral nerves lie in close proximity to the sacroiliac joint and may be injured during the procedure. A 49 year-old woman with a type C pelvic ring fracture was treated with an anterior sacroiliac plate using a computed tomography (CT)-three-dimensional (3D)-fluoroscopy matching navigation system, which visualized the lumbosacral nerves as well as the iliac and sacral bones. We used a flat panel detector 3D C-arm, which made it possible to superimpose our preoperative CT-based plan on the intra-operative 3D-fluoroscopic images. No postoperative complications were noted. Intra-operative lumbosacral nerve visualization using computer navigation was useful to recognize the 'at-risk' area for nerve injury during anterior sacroiliac plate fixation. Copyright © 2013 John Wiley & Sons, Ltd.

The distribution and origin of a novel brain peptide, neuropeptide Y, in the spinal cord of several mammals.

PubMed

Gibson, S J; Polak, J M; Allen, J M; Adrian, T E; Kelly, J S; Bloom, S R

1984-07-20

The distribution of neuropeptide Y [NPY]-immunoreactive material was examined in the spinal cord and dorsal root ganglia of rat, guinea-pig, cat, marmoset, and horse. Considerable concentrations of NPY and similar distribution patterns of immunoreactive nerve fibres were found in the spinal cord of all species investigated. The dorsal root ganglia of the cat and the horse contained numerous immunoreactive nerve fibres, but in these species, as in the other three studied [rat, guinea-pig, marmoset], no positively stained cell bodies were found. Neuropeptide Y-immunoreactive nerves were observed at all levels of the spinal cord, being most concentrated in the dorsal horn. In the rat, guinea-pig, and marmoset, there was a marked increase of NPY-immunoreactive fibres in the lumbosacral regions of the spinal cord, and this was reflected by a considerable increase of extractable NPY. Estimations of NPY-immunoreactive material in the various regions of the rat spinal cord were as follows: cervical, 13.8 +/- 1.0; thoracic, 21.1 +/- 2.5; lumbar, 16.3 +/- 2.9; sacral, 92.4 +/- 8.5 pmol/gm wet weight of tissue +/- SEM. In the ventral portion of the guinea-pig spinal cord they were as follows: cervical, 7.1 +/- 1.2; thoracic, 8.2 +/- 3.6; lumbar, 22.6 +/- 7.0; sacral, 36.7 +/- 9.5 pmol/gm wet weight of tissue +/- SEM. Analysis of spinal cord extracts by reverse phase high performance liquid chromatography [HPLC] demonstrated that NPY-immunoreactive material elutes in the position of pure NPY standard. No changes in the concentration and distribution of the NPY-like material in the rat spinal cord were observed following a variety of surgical and pharmacological manipulations, including cervical rhizotomy, sciatic nerve section and ligation, and local application of capsaicin [50 mM] to one sciatic nerve. It is therefore suggested that most of the NPY-immunoreactive material in the spinal cord is derived either from intrinsic nerve cell bodies or from supraspinal tracts.

[Functional dyspepsia, constipation and faecal incontinence].

PubMed

Wiesel, Paul; Frei, Alain

2007-01-24

Regarding functional dyspepsia, constipation, fecal incontinence, the main therapeutic acquisitions of the period are the following: for functional dyspepsia, remember that alarm signs are not absolute signs of seriousness; for constipation, encourage and repeat advises such as physical exercise; for fecal incontinence the transcutaneous neuro-modulation and the TENS (Transcutaneous Electrical Nerve Stimulation) are potential alternatives to sacral neuro-modulation.

Tibial nerve stimulation for overactive bladder syndrome unresponsive to medical therapy.

PubMed

Ridout, A E; Yoong, W

2010-02-01

Overactive bladder syndrome is defined as a symptom syndrome which includes urinary urgency, with or without urge incontinence, usually accompanied by frequency (>8 micturitions/24 h) and nocturia. Conservative treatment usually comprises behavioural techniques, bladder retraining, pelvic floor re-education and pharmacotherapy but up to 30% of patients will remain refractory to treatment. Although second-line treatment options such as sacral nerve stimulation and intravesical botulinum A injections are valuable additions to the therapeutic arsenal, they are relatively invasive and can have serious side-effects. Inhibition of detrusor activity by peripheral neuromodulation of the posterior tibial nerve was first described in 1983, with recent authors further confirming a 60-80% positive response rate. This review was undertaken to examine published literature on percutaneous tibial nerve stimulation and to discuss outcome measures, maintenance therapy and prognostic factors of this technique.

Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: a systematic literature review.

PubMed

Tawa, Nassib; Rhoda, Anthea; Diener, Ina

2017-02-23

Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate treatment of patients resulting in poor health outcomes, exacerbating this already debilitating condition. This review evaluated 12 primary diagnostic accuracy studies that specifically assessed the performance of various individual and grouped clinical neurological tests in detecting nerve root impingement, as established in the current literature. Eight electronic data bases were searched for relevant articles from inception until July 2016. All primary diagnostic studies which investigated the accuracy of clinical neurological test (s) in diagnosing lumbar radiculopathy among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the 'Quality Assessment of Diagnostic tests Accuracy Studies' criteria. A total of 12 studies which investigated standard components of clinical neurological examination of (sensory, motor, tendon reflex and neuro-dynamics) of the lumbo-sacral spine were included. The mean inter-observer agreement on quality assessment by two independent reviewers was fair (k = 0.3 - 0.7). The diagnostic performance of sensory testing using MR imaging as a reference standard demonstrated a sensitivity (confidence interval 95%) 0.61 (0.47-0.73) and a specificity of 0.63 (0.38-0.84). Motor tests sensitivity was poor to moderate, ranging from 0.13 (0.04-0.31) to 0.61 (0.36-0.83). Generally, the diagnostic performance of reflex testing was notably good with specificity ranging from (confidence interval 95%) 0.60 (0.51-0.69) to 0.93 (0.87-0.97) and sensitivity ranging from 0.14 (0.09-0.21) to 0.67 (0.21-0.94). Femoral nerve stretch test had a high sensitivity of (confidence interval 95%) 1.00 (0.40-1.00) and specificity of 0.83 (0.52-0.98) while SLR test recorded a mean sensitivity of 0.84 (0.72-0.92) and specificity of 0.78 (0.67-0.87). There is a scarcity of studies on the diagnostic accuracy of clinical neurological examination testing. Furthermore there seem to be a disconnect among researchers regarding the diagnostic utility of lower limb neuro-dynamic tests which include the Straight Leg Raise and Femoral Nerve tests for sciatic and femoral nerve respectively. Whether these tests are able to detect the presence of disc herniation and subsequent nerve root compression or hyper-sensitivity of the sacral and femoral plexus due to mechanical irritation still remains debatable.

Neuropeptide Y in human spinal cord.

PubMed

Allen, J M; Gibson, S J; Adrian, T E; Polak, J M; Bloom, S R

1984-08-06

The distribution of a newly described peptide, neuropeptide Y (NPY) within the human spinal cord has been determined using radioimmunoassay and immunocytochemistry. Higher concentrations were found in the lumbar (49.9 +/- 6.8 pmol/g) and sacral (47.0 +/- 10.6 pmol/g) regions than in the cervical (27.6 +/- 2.7 pmol/g) and thoracic spinal cord (33.8 +/- 5.3 pmol/g). Immunocytochemistry revealed numerous nerve fibers containing NPY in the spinal cord; these were particularly concentrated in the substantia gelatinosa of the dorsal horn. In the ventral spinal cord NPY-containing nerves were sparse becoming more abundant in lumbosacral segments.

Residual neurological function after sacral root resection during en-bloc sacrectomy: a systematic review.

PubMed

Zoccali, Carmine; Skoch, Jesse; Patel, Apar S; Walter, Christina M; Maykowski, Philip; Baaj, Ali A

2016-12-01

Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss of important function depending on the resection level and nerve roots sacrificed. The current literature regarding residual function after sacral resection comes from several small case series. The goal of this review is to appraise residual motor function and gait, sensitivity, bladder, bowel, and sexual function after sacrectomies, with consideration to the specific roots sacrificed. An exhaustive literature search was conducted. All manuscripts published before May 2015 regarding residual function after sacrectomy were considered; if a clear correlation between root level and functioning was not present, the paper was excluded. The review identified 15 retrospective case series, totaling 244 patients; 42 patients underwent sacrectomies sparing L4/L4, L4/L5 and L5/L5; 45 sparing both L5 and one or both S1 roots; 8 sparing both S1 and one S2; 48 sparing both S2; 11 sparing both S2 and one S3, 54 sparing both S3, 9 sparing both S3 and one or both S4, and 27 underwent unilateral variable resection. Patients who underwent a sacrectomy maintained functionally normal ambulation in 56.2 % of cases when both S2 roots were spared, 94.1 % when both S3 were spared, and in 100 % of more distal resections. Normal bladder and bowel function were not present when both S2 were cut. When one S2 root was spared, normal bladder function was present in 25 % of cases; when both S2 were spared, 39.9 %; when one S3 was spared, 72.7 %; and when both S3 were spared, 83.3 %. Abnormal bowel function was present in 12.5 % of cases when both S1 and one S2 were spared; in 50.0 % of cases when both S2 were spared; and in 70 % of cases when one S3 was spared; if both S3 were spared, bowel function was normal in 94 % of cases. When even one S4 root was spared, normal bladder and bowel function were present in 100 % of cases. Unilateral sacral nerve root resection preserved normal bladder function in 75 % of cases and normal bowel function in 82.6 % of cases. Motor function depended on S1 root involvement. Total sacrectomy is associated with compromising important motor, bladder, bowel, sensitivity, and sexual function. Residual motor function is dependent on sparing L5 and S1 nerve roots. Bladder and bowel function is consistently compromised in higher sacrectomies; nevertheless, the probability of maintaining sufficient function increases progressively with the roots spared, especially when S3 nerve roots are spared. Unilateral resection is usually associated with more normal function. To the best of our knowledge, this is the first comprehensive literature review to analyze published reports of residual sacral nerve root function after sacrectomy.

[Meningoradiculitis caused by herpes simplex virus type 2].

PubMed

Bollen, A E; Venema, A W; Veldkamp, K E

2007-10-27

A 24-year-old immune-competent woman was admitted to hospital with a three-day history of fever and headache. On examination bilateral facial nerve palsy, lumbosacral radicular pain, reduced sacral sensibility and urinary retention were found. Open perianal lesions were suspect for genital herpes. The symptoms were compatible with a meningoradiculitis including a sacral polyradiculitis. On testing, cerebrospinal fluid was found to be abnormal with a lymphocytic cell reaction. Polymerase chain reaction (PCR) of cerebrospinal fluid and of the perianal lesions was positive for herpes simplex virus type 2 (HSV-2). An MRI scan showed colouration of part of the cauda equina. The patient was treated by intravenous injections of acyclovir 10 mg/kg t.i.d. for 21 days, after which she completely recovered. HSV-2 infection of the nervous system can cause lymphocytic, and sometimes recurrent meningitis as well as sacral polyradiculitis. It may also occur without any symptomatic genital herpes infection. A positive result from a PCR test of the cerebrospinal fluid confirms this diagnosis. Treatment with acyclovir should be started as soon as possible.

Adhesive arachnoiditis after percutaneous fibrin glue treatment of a sacral meningeal cyst.

PubMed

Hayashi, Kazunori; Nagano, Junji; Hattori, Satoshi

2014-06-01

The authors present the case of a 64-year-old woman who was referred for severe sacral pain. She reported that her pain had been longstanding, and had greatly increased after percutaneous fibrin glue placement therapy for a sacral meningeal cyst 2 months earlier at a different hospital. An MRI scan obtained immediately after fibrin glue placement at that hospital suggested that fibrin glue had migrated superiorly into the subarachnoid space from the sacral cyst to the level of L-4. On admission to the authors' institution, physical examination demonstrated no abnormal findings except for perianal hypesthesia. An MRI study obtained at admission demonstrated a cystic lesion in the peridural space from the level of S-2 to S-4. Inhomogeneous intensity was identified in this region on T2-weighted images. Because the cauda equina and nerve roots appeared to be compressed by the lesion, total cyst excision was performed. The cyst cavity was filled with fluid that resembled CSF, plus gelatinous material. Histopathological examination revealed that the cyst wall was composed of hyaline connective tissue with some calcification. No nervous tissue or ganglion cells were found in the tissue. The gelatinous material was acellular, and appeared to be degenerated fibrin glue. Sacral pain persisted to some extent after surgery. The authors presumed that migrated fibrin glue caused the development of adhesive arachnoiditis. The risk of adhesive arachnoiditis should be considered when this therapy is planned. Communication between a cyst and the subarachnoid space should be confirmed to be sufficiently narrow to prevent the migration of injected fibrin glue.

Systematization of the vesical and uterovaginal efferences of the female inferior hypogastric plexus (pelvic): applications to pelvic surgery on women patients.

PubMed

Mauroy, B; Bizet, B; Bonnal, J L; Crombet, T; Duburcq, T; Hurt, C

2007-04-01

To locate and describe the various efferences of the plexus in order to make it easier to avoid nerve lesions during pelvic surgery on women patients through a better anatomical knowledge of the inferior hypogastric plexus (IHP). We dissected 27 formalin embalmed female anatomical subjects, none of which bore any stigmata of subumbilical surgery. The dissection was always performed using the same technique: identification of the inferior hypogastric plexus, whose posterior superior angle follows on from the hypogastric nerve and whose top, which is anterior and inferior, is located exactly at the ureter's point of entry into the base of the parametrium, underneath the posterior layer of the broad ligament. The IHP is located at the level of the posterior floor of the pelvis, opposite to the sacral concavity. Its top, which is anterior inferior, is at the point of contact with the ureter at its entry into the posterior layer of the broad ligament. The uterovaginal, vesical and rectal efferences originate in the paracervix. Three efferent nerves branch, two of them from its top and the third from its inferior edge: (1) A vaginal nerve, medial to the ureter, follows the uterine artery and divides into two groups: anterior thin, heading for the vagina and the uterus; posterior, voluminous, heading in a superior rectal direction (=superior rectal nerve). (2) A vesical nerve, lateral to the ureter, divides into two groups, lateral and medial. (3) The inferior rectal nerve emerges from the inferior edge of the IHP, between the fourth sacral root and the ureter's point of entry into the base of the parametrium. The ureter is the crucial point of reference for the IHP and its efferences and acts as a real guide for identifying the anterior inferior angle or top of the IHP, the origin of the vaginal nerve, the level of the ureterovesical junction and the division of the vesical nerve into its two medial and lateral branches. Dissecting underneath and inside the ureter and the uterine artery involves a risk of lesion of the vaginal nerve and its uterovaginal branches. Further forward, between the intersection and the ureterovesical junction, dissecting and/or coagulating under the ureter involves a risk of lesions to the vesical nerve, which are likely to explain the phenomena of denervation of the anterior floor encountered after certain hysterectomies and/or surgical treatments of vesicoureteral reflux.

Physiology of male sexual function.

PubMed

deGroat, W C; Booth, A M

1980-02-01

The male sexual response cycle consists of excitement, plateau, orgasm, and resolution. The initial event, penile erection, is produced by arteriolar dilatation and increased blood flow to the erectile tissue of the penis. Erection is a reflex response initiated by visual, olfactory, or imaginative stimuli impinging upon supraspinal centers or by genital stimulation that in turn activates spinal reflex mechanisms. Sacral parasympathetic and thoracolumbar sympathetic nerves provide the efferent vasodilator input to the penis. Parasympathetic nerves also stimulate secretion from the seminal vesicles and prostate and Cowper's glands during the plateau phase. The orgasmic phase is characterized by seminal emission and ejaculation and the accompanying sensations. Emission of semen into the urethra depends on sympathetic nerves that elicit contractions of smooth muscles in the vas deferens, seminal vesicles, and prostate. Rhythmic contractions of striated muscle (bulbocavernosus and ischiocavernosus) generated by efferent pathways in the pudendal nerve eject semen from the urethra.

Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing.

PubMed

Schildhauer, T A; Josten, Ch; Muhr, G

2006-01-01

Presentation of a new triangular osteosynthesis technique that permits early weight-bearing in vertically unstable sacral fractures. : Retrospective evaluation of a consecutive series. Level I trauma center. Thirty-four patients, twenty-eight of whom were poly-traumatized, all with vertically unstable sacral fractures. This group included eight women and twenty-six men, with a mean age of thirty-five years. Average time between trauma and definite operation was thirteen days (range 0 to 28 days). All patients underwent triangular osteosynthesis using a combination of a vertical vertebro-pelvic distraction osteosynthesis (pedicle screw system) and a transverse fixation of the sacrum fracture with either iliosacral screws or trans-sacral plating. Immediate postoperative weight-bearing was permitted postoperatively. Nineteen patients were treated with early progressive weight-bearing and advanced to full weight-bearing, on average, after twenty-three days (range 8 to 70 days). Three of the thirty-four patients (9 percent) experienced loosening of hardware, including two patients (6 percent) who required secondary intervention because of loss of the original reduction. Further complications included one pulmonary embolism (3 percent), one iatrogenic nerve lesion (3 percent), one wound necrosis (3 percent), and two local infections (6 percent). Triangular osteosynthesis is a demanding procedure that can be performed on vertically unstable sacral fractures to allow early progressive weight-bearing with an acceptable complication rate.

The anatomy of the sacrococcygeal cornual region and its clinical relevance.

PubMed

Woon, Jason T K; Stringer, Mark D

2014-09-01

There has been no systematic study of the anatomy of the region between the sacral and coccygeal cornua. Reference texts describe an intercornual ligament connecting these structures. The aim of this study was to investigate the anatomy of this region, which may be relevant to unexplained cases of coccygeal pain (coccydynia) and local nerve blocks. The bony anatomy of the sacrococcygeal (SC) cornual region was analyzed in 33 CT scans obtained from supine adults of mostly European origin with no known SC pathology, 7 μCT scans of cadaver SC specimens, and 105 Asian Indian adult skeletons. A further five cadaver SC specimens were examined histologically. SC cornual fusion was seen in 45% of CT/μCT scans (mean age 67 years, 20 males) and in 20% of adult skeletons (78 males); there was no association with age or sex. In the absence of SC fusion, the mean intersacrococcygeal cornual gap was 7.1 ± 2.4 mm; this was bridged by an intercornual ligament composed of parallel vertical collagen fibers reinforced by elastin fibers on its anterior surface. Small nerve branches were observed adjacent to the ventral aspect of the intercornual ligament and, in one case, traversing the ligament. Ipsilateral sacral and coccygeal cornua are therefore normally bridged by an intercornual ligament that is probably innervated. The cornua are fused on one or both sides in 20-45% of adults. These findings may have implications for some cases of coccydynia and for anesthetists performing local nerve blocks.

Sacral nerve stimulation enhances epithelial barrier of the rectum: results from a porcine model.

PubMed

Meurette, G; Blanchard, C; Duchalais-Dassonneville, E; Coquenlorge, S; Aubert, P; Wong, M; Lehur, P-A; Neunlist, M

2012-03-01

The mechanism of action of sacral nerve stimulation (SNS) remains largely elusive. The aims of this study were to develop a clinically relevant animal model for percutaneous SNS and to describe its effect on the epithelial barrier of the rectum. Under general anesthesia and after percutaneous electrode placement for S3 nerve root stimulation, six pigs underwent unilateral stimulation and six bilateral stimulation. Animals were stimulated for 3 h using an external pulse generator (1-2.5 V; 14 Hz; 210 μs). Six animals underwent electrode implantation without stimulation and served as controls. Full-thickness rectal biopsies were performed prior to and after stimulation. Paracellular permeability was evaluated by measuring sulfonic acid flux across the rectal mucosa in Ussing chambers. Histological assessment of mucosal thickness, epithelial desquamation, and mucus expression were performed. Percutaneous stimulation resulted in successful anal contractions whose amplitude and uniformity was enhanced following bilateral compared with unilateral stimulation. In controls, paracellular permeability significantly increased during the stimulation period whereas it remained unchanged following unilateral stimulation. In contrast, permeability was significantly reduced by bilateral stimulation. This effect was associated with a concomitant reduction in mucosal thickness and a trend toward increased amount of mucus on surface epithelium compared with controls. The development of a porcine model of percutaneous SNS revealed the ability of neuromodulation to reinforce rectal epithelial barrier. Furthermore, our results suggest that SNS could be used for treatment of gastrointestinal pathologies with reduced rectal mucosal barrier functions. © 2012 Blackwell Publishing Ltd.

[Hypobaric 0.15% bupivacaine versus hyperbaric 0.5% bupivacaine for posterior (dorsal) spinal block in outpatient anorectal surgery.].

PubMed

Imbelloni, Luiz Eduardo; Vieira, Eneida Maria; Gouveia, M A; Netinho, João Gomes; Cordeiro, José Antonio

2006-12-01

The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Mood's median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 +/- 25 minutes and in 95 +/- 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done.

[Indications and possibilities of blockade of the sympathetic nerve].

PubMed

Meyer, J

1987-04-01

Treatment of chronic pain through permanent or temporary interruption of sympathetic activity is marked by great clinical success, but nevertheless there are rather skeptical reports about long-term results of these blocks as therapeutic measures. There are many symptoms and signs of chronic pain, while diagnosis is expensive, the pathogenesis is complex, and the etiology is generally due to multiple factors. Indications for sympathetic blockade depend upon the possible means of access, as in the cervicothoracic, thoracic, lumbar, or sacral regions. General indications are: symptoms not limited segmentally within peripheral body areas; pain resulting from microtraumata and lesions of peripheral nerve branches; and pain caused by intensified sympathetic tone with consequent circulatory disturbances. Peripheral circulatory disturbances are the most common indication for sympathetic blockade, as the block produces a vasomotor reaction that leads to increased capillary circulation. Pain caused by herpes zoster, sudden hearing loss, hyperhidrosis, and pseudesthesia can also be influenced by sympathetic blockade. There are several possibilities for reducing or interrupting sympathetic activity; for us, however, blocking of the sympathetic trunk is the most important. During the last 16 years we performed 15,726 sympathetic blockades on 2385 patients, which included: 3735 stellate ganglion blocks, 6121 blocks of the lumbar sympathetic trunk, 5037 continuous peridural anesthesias, 29 blocks of the thoracic sympathetic trunk, and 12 celiac blocks. In 792 cases sympathetic blocks were performed using neurolytic drugs, in most cases 96% ethyl alcohol and less often 10% ammonium sulphate. Other possibilities, such as enteral administration or infusion of sympatholytic drugs, were not taken into consideration; regional intravascular injection of guanethidine can be recommended, however.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphology of the caudal spinal cord in Rana (Ranidae) and Xenopus (Pipidae) tadpoles.

PubMed

Nishikawa, K; Wassersug, R

1988-03-08

Using a variety of neuroanatomical and histological techniques, we compare the spinal cord and peripheral nerve distribution in the tails of larvae from Xenopus laevis and three species of Rana. The relatively large, postsacral spinal cord of Xenopus contains abundant motoneurons and their axons. Spinal nerves exit from the spinal cord in a regular array, one nerve per myotome, from the cervical region to near the end of the tail. Somata of motoneurons innervating caudal myotomes are found along the entire length of the tail. In contrast, the caudal cord of Rana is reduced to a filum terminale consisting of little more than an ependymal tube; spinal nerves to all caudal myotomes leave the cord in the sacral region and reach their motor targets via a cauda equina and caudal plexus. Motoneuron cell bodies innervating caudal myotomes are found only in the sacral region. The Rana larval pattern is similar to that of adult frogs and mammals, whereas the Xenopus larval pattern is more like that of salamanders and reptiles. These gross neuroanatomical differences are not due to differences in the size or developmental stage of the tadpoles, but instead are associated with differences in the swimming behavior of the larvae. The presence of motoneurons in the caudal spinal cord of Xenopus may provide local intermyotomal control within the tail; the elongated topography of the cord appears to permit finer, rostral-to-caudal regulation of neuromuscular activity. The Rana spinal cord, on the other hand--with motoneurons clustered anteriorly--may produce concurrent firing of adjacent ipsilateral myotomes, but at the expense of fine intermyotomal regulation. The fact that nerves in the tail of Xenopus enter and exit from the spinal cord locally, as opposed to far anteriorly as in Rana, means that for tadpoles of the same size, reflex arc lengths are many times shorter in Xenopus.

Can Navigation-assisted Surgery Help Achieve Negative Margins in Resection of Pelvic and Sacral Tumors?

PubMed

Abraham, John A; Kenneally, Barry; Amer, Kamil; Geller, David S

2018-03-01

Navigation-assisted resection has been proposed as a useful adjunct to resection of malignant tumors in difficult anatomic sites such as the pelvis and sacrum where it is difficult to achieve tumor-free margins. Most of these studies are case reports or small case series, but these reports have been extremely promising. Very few reports, however, have documented benefits of navigation-assisted resection in series of pelvic and sacral primary tumors. Because this technology may add time and expense to the surgical procedure, it is important to determine whether navigation provides any such benefits or simply adds cost and time to an already complex procedure. (1) What proportion of pelvic and sacral bone sarcoma resections utilizing a computer-assisted resection technique achieves negative margins? (2) What are the oncologic outcomes associated with computer-assisted resection of pelvic and sacral bone sarcomas? (3) What complications are associated with navigation-assisted resection? Between 2009 and 2015 we performed 24 navigation-assisted resections of primary tumors of the pelvis or sacrum. Of those, four were lost to followup after the 2-year postoperative visit. In one patient, however, there was a failure of navigation as a result of inadequate imaging, so nonnavigated resection was performed; the remaining 23 were accounted for and were studied here at a mean of 27 months after surgery (range, 12-52 months). During this period, we performed navigation-assisted resections in all patients presenting with a pelvis or sacral tumor; there was no selection process. No patients were treated for primary tumors in these locations without navigation during this time with the exception of the single patient in whom the navigation system failed. We retrospectively evaluated the records of these 23 patients and evaluated the margin status of these resections. We calculated the proportion of patients with local recurrence, development of metastases, and overall survival at an average 27-month followup (range, 12-52 months). We queried a longitudinally maintained surgical database for any complications and noted which, if any, could have been directly related to the use of the navigation-assisted technique. In our series, 21 of 23 patients had a negative margin resection. In all patients the bone margin was negative, but two with sacral resections had positive soft tissue margins. Six of 23 patients experienced local recurrence within the study period. Three patients died during the study period. Seventeen patients demonstrated no evidence of disease at last recorded followup. We noted three intraoperative complications: one dural tear, one iliac vein laceration, and one bladder injury. Eight patients out of 23 had wound complications resulting in operative débridement. Two patients in the series developed transient postoperative femoral nerve palsy, which we believe were caused by stretch of the femoral nerve secondary to the placement of the reference array in the pubic ramus. Navigation-assisted resection of pelvic and sacral tumors resulted in a high likelihood of negative margin resection in this series, and we observed relatively few complications related specifically to the navigation. We have no comparison group without navigation, and future studies should indeed compare navigated with nonnavigated resection approaches in these anatomic locations. We did identify a potential navigation-related complication of femoral nerve palsy in this series and suggest careful placement and observation of the reference array during the operative procedure to lessen the likelihood of this previously unreported complication. We suggest it is worthwhile to consider the use of navigation-assisted surgery in resection of tumors of the pelvis and sacrum, but further study will be needed to determine its precise impact, if any, on local recurrence and other oncologic outcomes. Level IV, therapeutic study.

PHASE II STUDY OF HIGH DOSE PHOTON/PROTON RADIOTHERAPY IN THE MANAGEMENT OF SPINE SARCOMAS

PubMed Central

DeLaney, Thomas F.; Liebsch, Norbert J.; Pedlow, Francis X.; Adams, Judith; Dean, Susan; Yeap, Beow Y.; McManus, Patricia; Rosenberg, Andrew E.; Nielsen, G. Petur; Harmon, David C.; Spiro, Ira J.; Raskin, Kevin A.; Suit, Herman D.; Yoon, Sam S.; Hornicek, Francis J.

2009-01-01

Purpose Radiotherapy (XRT) for spine sarcomas is constrained by spinal cord, nerve, and viscera tolerance. Negative surgical margins are uncommon; hence, doses of ≥ 66 Gy are recommended. A Phase II clinical trial evaluated high dose photon/proton XRT for spine sarcomas. Materials/Methods Eligible patients had non-metastatic, thoracic, lumbar, and/or sacral spine/paraspinal sarcomas. Treatment included pre- and/or post-op photon/proton XRT +/- radical resection; patients with osteosarcoma and Ewing's sarcoma received chemotherapy. Shrinking fields delivered 50.4 cobalt Gray equivalent (GyRBE) to subclinical disease, 70.2 GyRBE to microscopic disease in the tumor bed, and 77.4 GyRBE to gross disease at 1.8 GyRBE q.d. Doses were reduced for radiosensitive histologies, concurrent chemoradiation, or when diabetes or autoimmune disease present. Spinal cord dose was limited to 63/54 GyRBE to surface/center. Intra-operative boost doses of 7.5-10 Gy could be given by dural plaque. Results 50 patients (29 chordoma, 14 chondrosarcoma, 7 other) underwent gross total (n=25) or subtotal (n=12) resection or biopsy (n=13). With 48 month median follow-up, five-year actuarial local control, recurrence-free survival, and overall survival are: 78%, 63%, and 87% respectively. Two of 36 (5.6%) patients treated for primary versus 7/14 (50%) for recurrent tumor developed local recurrence, p<0.001. Five patients developed late radiation-associated complications; no myelopathy developed but three sacral neuropathies appeared following 77.12-77.4 GyRBE. Conclusions Local control with this treatment is high in patients radiated at the time of primary presentation. Spinal cord dose constraints appear to be safe. Sacral nerves receiving 77.12-77.4 GyRBE are at risk for late toxicity. PMID:19095372

Efficacy of pudendal nerve block for alleviation of catheter-related bladder discomfort in male patients undergoing lower urinary tract surgeries: A randomized, controlled, double-blind trial.

PubMed

Xiaoqiang, Li; Xuerong, Zhang; Juan, Liu; Mathew, Bechu Shelley; Xiaorong, Yin; Qin, Wan; Lili, Luo; Yingying, Zhu; Jun, Luo

2017-12-01

Catheter-related bladder discomfort (CRBD) to an indwelling urinary catheter is defined as a painful urethral discomfort, resistant to conventional opioid therapy, decreasing the quality of postoperative recovery. According to anatomy, the branches of sacral somatic nerves form the afferent nerves of the urethra and bladder triangle, which deriving from the ventral rami of the second to fourth sacral spinal nerves, innervating the urethral muscles and sphincter of the perineum and pelvic floor; as well as providing sensation to the penis and clitoris in males and females, which including the urethra and bladder triangle. Based on this theoretical knowledge, we formed a hypothesis that CRBD could be prevented by pudendal nerve block. To evaluate if bilateral nerve stimulator-guided pudendal nerve block could relieve CRBD through urethra discomfort alleviation. Single-center randomized parallel controlled, double blind trial conducted at West China Hospital, Sichuan University, China. One hundred and eighty 2 male adult patients under general anesthesia undergoing elective trans-urethral resection of prostate (TURP) or trans-urethral resection of bladder tumor (TURBT). Around 4 out of 182 were excluded, 178 patients were randomly allocated into pudendal and control groups, using computer-generated randomized numbers in a sealed envelope method. A total of 175 patients completed the study. Pudendal group received general anesthesia along with nerve-stimulator-guided bilateral pudendal nerve block and control group received general anesthesia only. Incidence and severity of CRBD; and postoperative VAS score of pain. CRBD incidences were significantly lower in pudendal group at 30 minutes (63% vs 82%, P = .004), 2 hours (64% vs 90%, P < .000), 8 hours (58% vs 79%, P = .003) and 12 hours (52% vs 69%, P = .028) also significantly lower incidence of moderate to severe CRBD in pudendal group at 30 minutes (29% vs 57%, P < .001), 2 hours (22% vs 55%, P < .000), 8 hours (8% vs 27%, P = .001) and 12 hours (6% vs 16%, P = .035) postoperatively. The postoperative pain score in pudendal group was lower at 30 minutes (P = .003), 2 hours (P < .001), 8 hours (P < .001), and 12 hours (P < .001), with lower heart rate and mean blood pressure. One patient complained about weakness in levator ani muscle. General anesthesia along with bilateral pudendal nerve block decreased the incidence and severity of CRBD for the first 12 hours postoperatively.

A Fully Implanted Drug Delivery System for Peripheral Nerve Blocks in Behaving Animals

PubMed Central

Pohlmeyer, Eric A.; Jordon, Luke R.; Kim, Peter; Miller, Lee E.

2009-01-01

Inhibiting peripheral nerve function can be useful for many studies of the nervous system or motor control. Accomplishing this in a temporary fashion in animal models by using peripheral nerve blocks permits studies of the immediate effects of the loss, and/or any resulting short-term changes and adaptations in behavior or motor control, while avoiding the complications commonly associated with permanent lesions, such as sores or self-mutilation. We have developed a method of quickly and repeatedly inducing temporary, controlled motor deficits in rhesus macaque monkeys via a chronically implanted drug delivery system. This assembly consists of a nerve cuff and a subdermal injection dome, and has proved effective for delivering local anesthetics directly to peripheral nerves for many months. Using this assembly for median and ulnar nerve blocks routinely resulted in over 80% losses in hand and wrist strength for rhesus monkeys. The assembly was also effective for inducing ambulatory motor deficits in rabbits through blocks of the sciatic nerve. Interestingly, while standard anesthetics were sufficient for the rabbit nerve blocks, the inclusion of epinephrine was essential for achieving significant motor blockade in the monkeys. PMID:19524613

Electrical management of neurogenic lower urinary tract disorders.

PubMed

Joussain, C; Denys, P

2015-09-01

Management of lower urinary tract dysfunction (LUTD) in neurological diseases remains a priority because it leads to many complications such as incontinence, renal failure and decreased quality of life. A pharmacological approach remains the first-line treatment for patients with neurogenic LUTD, but electrical stimulation is a well-validated and recommended second-line treatment. However, clinicians must be aware of the indications, advantages and side effects of the therapy. This report provides an update on the 2 main electrical stimulation therapies for neurogenic LUTD - inducing direct bladder contraction with the Brindley procedure and modulating LUT physiology (sacral neuromodulation, tibial posterior nerve stimulation or pudendal nerve stimulation). We also describe the indications of these therapies for neurogenic LUTD, following international guidelines, as illustrated by their efficacy in patients with neurologic disorders. Electrical stimulation could be proposed for neurogenic LUTD as second-line treatment after failure of oral pharmacologic approaches. Nevertheless, further investigations are needed for a better understanding of the mechanisms of action of these techniques and to confirm their efficacy. Other electrical investigations, such as deep-brain stimulation and repetitive transcranial magnetic stimulation, or improved sacral anterior root stimulation, which could be associated with non-invasive and highly specific deafferentation of posterior roots, may open new fields in the management of neurogenic LUTD. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Iliac screw for reconstructing posterior pelvic ring in Tile type C1 pelvic fractures.

PubMed

Li, Yonggang; Sang, Xiguang; Wang, Zhiyong; Cheng, Lin; Liu, Hao; Qin, Tao; Di, Kai

2018-06-18

It is often difficult to achieve stable fixation in Tile type C1 pelvic fractures and there is no standard fixation technique for these types of injuries. Iliac screw fixation can be used for treating Type C1 pelvic fractures. A retrospective review was performed on 47 patients who underwent iliac screw fixation in posterior column of ilium (PCI) for Tile type C1 pelvic fractures from July 2007 to December 2014. All patients were treated with fracture reduction, sacral nerve root decompression (if needed), internal fixation by iliac screw and connecting rod. The data on surgical time, intraoperative bleeding volume, postoperative neurologic functions and postoperative complications were analyzed. Patients were follow-up for at least 12months. The mean surgical time was 148minutes, and the mean intraoperative bleeding volume was 763ml. Patients were encouraged in-bed activities immediately after surgery. The postoperative Majeed functional score was 48-100 points (mean 80.2), corresponding to an excellent and good recovery of 91.5%. Postoperative X-radiographs and CT scans indicated satisfactory fracture reduction. Iliac screw fixation combined with sacral nerve canal decompression could effectively restore pelvic alignment and improve neurological functions for complex pelvic trauma. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

The biology of herpes simplex virus infection in humans.

PubMed

Baringer, J R

1976-01-01

Herpes simplex virus is a frequent cause of recurrent ocular, oral, genital or cutaneous eruptions in man. Lesions are highly localized and tend to recur at the same site. Among the most consistent factors provoking recurrence is root section of the trigeminal nerve. Clinical and experimental data suggest that herpes simplex virus is commonly resident within the trigeminal ganglia of man, where it may be responsible for recurrent oral or lip lesions, and is less frequently a resident of the second or third sacral ganglia where it might be responsible for genital eruptions. Generally, the trigeminal virus is type 1 and the sacral virus is type 2; the virus is only rarely recoverable from other sensory ganglia. Factors provoking the reactivation from the virus' latent site and the mechanism for reactivation remain largely unknown. Further study is needed to understand the behavior of HSV and other viruses in nervous system tissue.

New Stimulation Strategy to Improve the Bladder Function in Paraplegics: Chronic Experiments in Dogs

DTIC Science & Technology

2001-10-25

urinary system [4]. More recently, neurostimulation and neuromodulation of the sacral nerve root seems to be one of the most promising options to enhance...day. Expelled and residual urine volumes were measured. Also the applied parameters for the continuous low frequency / low amplitude neuromodulation ...VCUG) with neurostimulation was carried out after IVU study. Low-frequency only stimulation During the 7th month, daily stimulations were performed

Efficacy of pudendal nerve block for alleviation of catheter-related bladder discomfort in male patients undergoing lower urinary tract surgeries

PubMed Central

Xiaoqiang, Li; Xuerong, Zhang; Juan, Liu; Mathew, Bechu Shelley; Xiaorong, Yin; Qin, Wan; Lili, Luo; Yingying, Zhu; Jun, Luo

2017-01-01

Abstract Background: Catheter-related bladder discomfort (CRBD) to an indwelling urinary catheter is defined as a painful urethral discomfort, resistant to conventional opioid therapy, decreasing the quality of postoperative recovery. According to anatomy, the branches of sacral somatic nerves form the afferent nerves of the urethra and bladder triangle, which deriving from the ventral rami of the second to fourth sacral spinal nerves, innervating the urethral muscles and sphincter of the perineum and pelvic floor; as well as providing sensation to the penis and clitoris in males and females, which including the urethra and bladder triangle. Based on this theoretical knowledge, we formed a hypothesis that CRBD could be prevented by pudendal nerve block. Objective: To evaluate if bilateral nerve stimulator-guided pudendal nerve block could relieve CRBD through urethra discomfort alleviation. Design and Setting: Single-center randomized parallel controlled, double blind trial conducted at West China Hospital, Sichuan University, China. Participants: One hundred and eighty 2 male adult patients under general anesthesia undergoing elective trans-urethral resection of prostate (TURP) or trans-urethral resection of bladder tumor (TURBT). Around 4 out of 182 were excluded, 178 patients were randomly allocated into pudendal and control groups, using computer-generated randomized numbers in a sealed envelope method. A total of 175 patients completed the study. Intervention: Pudendal group received general anesthesia along with nerve-stimulator-guided bilateral pudendal nerve block and control group received general anesthesia only. Main outcome measures: Incidence and severity of CRBD; and postoperative VAS score of pain. Results: CRBD incidences were significantly lower in pudendal group at 30 minutes (63% vs 82%, P = .004), 2 hours (64% vs 90%, P < .000), 8 hours (58% vs 79%, P = .003) and 12 hours (52% vs 69%, P = .028) also significantly lower incidence of moderate to severe CRBD in pudendal group at 30 minutes (29% vs 57%, P < .001), 2 hours (22% vs 55%, P < .000), 8 hours (8% vs 27%, P = .001) and 12 hours (6% vs 16%, P = .035) postoperatively. The postoperative pain score in pudendal group was lower at 30 minutes (P = .003), 2 hours (P < .001), 8 hours (P < .001), and 12 hours (P < .001), with lower heart rate and mean blood pressure. One patient complained about weakness in levator ani muscle. Conclusion: General anesthesia along with bilateral pudendal nerve block decreased the incidence and severity of CRBD for the first 12 hours postoperatively. PMID:29245259

The cost-effectiveness of sacral nerve stimulation (SNS) for the treatment of idiopathic medically refractory overactive bladder (wet) in the UK.

PubMed

Autiero, Silke Walleser; Hallas, Natalie; Betts, Christopher D; Ockrim, Jeremy L

2015-12-01

To estimate the long-term cost-effectiveness of specialised treatment options for medically refractory idiopathic overactive bladder (OAB) wet. The cost-effectiveness of competing treatment options for patients with medically refractory idiopathic OAB wet was estimated from the perspective of the National Health Service in the UK. We compared sacral nerve stimulation (SNS) with percutaneous nerve evaluation (PNE) or tined-lead evaluation (TLE) with optimal medical therapy (OMT), botulinum toxin type A (BoNT-A) injections, and percutaneous tibial nerve stimulation (PTNS). We used a Markov model with a 10-year time horizon for all treatment options with the exception of PTNS, which has a time horizon of 5 years. Costs and effects (measured as quality-adjusted life years) were calculated to derive incremental cost-effectiveness ratios (ICERs). Direct medical resources included are: device and drug acquisition costs, pre-procedure and procedure costs, and the cost of managing adverse events. Deterministic sensitivity analyses were performed to test robustness of results. At 5 years, SNS (PNE or TLE) was more effective and less costly than PTNS. Compared with OMT at 10 years, SNS (PNE or TLE) was more costly and more effective, and compared with BoNT-A, SNS PNE was less costly and more effective, and SNS TLE was more costly and more effective. Decreasing the BoNT-A dose from 150 to 100 IU marginally increased the 10 year ICERs for SNS TLE and PNE (SNS PNE was no longer dominant). However, both SNS options remained cost-effective. In the management of patients with idiopathic OAB wet, the results of this cost-utility analysis favours SNS (PNE or TLE) over PTNS or OMT, and the most efficient treatment strategy is SNS PNE over BoNT-A over a 10-year period. © 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.

[Herpes zoster of the trigeminal nerve: a case report and review of the literature].

PubMed

Carbone, V; Leonardi, A; Pavese, M; Raviola, E; Giordano, M

2004-01-01

Herpes zoster (shingles) is caused when the varicella zoster virus that has remained latent since an earlier varicella infection (chicken-pox) is reactivated. Herpes Zoster is a less common and endemic disease than varicella: factors causing reactivation are still not well known, but it occurs in older and/or immunocompromised individuals. Following reactivation, centrifugal migration of herpes zoster virus (HZV) occurs along sensory nerves to produce a characteristic painful cutaneous or mucocutaneous vesicular eruption that is generally limited to the single affected dermatome. Herpes zoster may affect any sensory ganglia and its cutaneous nerve: the most common sites affected are thoracic dermatomes (56%), followed by cranial nerves (13%) and lumbar (13%), cervical (11%) and sacral nerves (4%). Among cranial nerves, the trigeminal and facial nerves are the most affected due to reactivation of HZV latent in gasserian and geniculated ganglia. The 1st division of the trigeminal nerve is commonly affected, whereas the 2nd and the 3rd are rarely involved. During the prodromal stage, the only presenting symptom may be odontalgia, which may prove to be a diagnostic challenge for the dentist, since many diseases can cause orofacial pain, and the diagnosis must be established before final treatment. A literature review of herpes zoster of the trigeminal nerve is presented and the clinical presentation, differential diagnosis and treatment modalities are underlined. A case report is presented.

Neuromodulation by implant for treating lower urinary tract symptoms and dysfunction.

PubMed

Bemelmans, B L; Mundy, A R; Craggs, M D

1999-08-01

Patients with irritative micturition complaints, pelvic pain, involuntary urine loss or urinary retention are sometimes difficult to treat. The advent of direct sacral nerve stimulation offers a therapeutic alternative if conservative measures fail and surgery is considered. This paper reviews therapeutic neuromodulation by implant for treating lower urinary tract symptoms and dysfunction. The international literature is reviewed on topics such as the physiological basis of neuromodulation, techniques of acute testing and chronic implantation, and clinical results. Future developments and ways for possible improvement are discussed. The mode of action of neuromodulation is probably through restoring the correct balance between excitatory and inhibitory impulses from and to the pelvic organs at a sacral and supra-sacral level. Depending on the predefined success criteria, average success rates of definitive implants vary from 50 to 70%. From the data it seems that patients with urge incontinence and urinary retention are the best candidates for neuromodulation. In the literature the lack of standardisation of selection criteria, stimulation parameters and definitions of success is striking. Neuromodulation by implant is a useful therapeutic alternative. It should at least be considered in patients with therapy-resistant urge incontinence and urinary retention before proceeding to surgery. Issues such as underlying physiology, methodological standardisation, technical improvements, and patient selection must be addressed in future research.

Feasibility of controlled micturition through electric stimulation.

PubMed

Schmidt, R A; Tanagho, E A

1979-01-01

Historically, man has been aware of bioelectric phenomena for some 4,000 years. Yet it has only been during the last 20 years that technology has advanced to the stage where controlled bladder emptying has become feasible. A great deal of interest followed the introduction of transistor and bladder stimulation via the principle of radio frequency induction. Spinal cord, sacral, and pelvic nerve and direct bladder stimulation have all been attempted. Only direct bladder stimulation in lower motor neuron situations has shown any promise. The many difficulties associated with bladder stimulation include simultaneous sphincter contraction, pain, electrode and insulation difficulties, and fibroplasia due to movement of electrodes placed in pliable tissues. In addition, the role of the prostate, increased urethral length, and erection responses in the male have received little investigation. These problems are outlined and experimental observations of attempts to achieve controlled micturition in canines areresented. These studies were carried out over a 3-year period, and emphasize responses to stimulation of the spinal cord and sacral roots. It was concluded that the most efficient manner by which to effect simulated micturition is via stimulation of the ventral sacral root dominant for bladder responsiveness, and combine this with selective division of somatic fibers of only the root being stimulated.

Double Crush of L5 Spinal Nerve Root due to L4/5 Lateral Recess Stenosis and Bony Spur Formation of Lumbosacral Transitional Vertebra Pseudoarticulation: A Case Report and Review

PubMed Central

Iwasaki, Motoyuki; Akiyama, Masahiko; Koyanagi, Izumi; Niiya, Yoshimasa; Ihara, Tatsuo; Houkin, Kiyohiro

2017-01-01

We present a case of double-crushed L5 nerve root symptoms caused by inside and outside of the spinal canal with spur formation of the lumbosacral transitional vertebra (LSTV). A 78-year-old man presented with 7-year history of moderate paresis of his toe and left leg pain when walking. Magnetic resonance imaging (MRI) revealed spinal stenosis at the L3/4 and 4/5 spinal levels and he underwent wide fenestration of both levels. Leg pain disappeared and 6-min walk distance (6MWD) improved after surgery, however, the numbness in his toes increased and 6MWD decreased 9 months after surgery. Repeated MR and 3D multiplanar reconstructed computed tomography (CT) images showed extraforaminal impingement of the L5 root by bony spur of the left LSTV. He underwent second decompression surgery of the L5/S via the left sided Wiltse approach, resulting in the improvement of his symptoms. The impingement of L5 spinal nerve root between the transverse process of the fifth lumbar vertebra and the sacral ala is a rare entity of the pathology called “far-out syndrome (FOS)”. Especially, the bony spur formation secondary to the anomalous articulation of the LSTV (LSPA) has not been reported. These articulations could be due to severe disc degeneration, following closer distance and contact between the transverse process and the sacral ala. To our knowledge, this is the first report describing a case with this pathology and may be considered in cases of failed back surgery syndromes (FBSS) of the L5 root symptoms. PMID:29018654

Restoring penis sensation in patients with low spinal cord lesions: the role of the remaining function of the dorsal nerve in a unilateral or bilateral TOMAX procedure.

PubMed

Overgoor, Max L E; Braakhekke, Jan P; Kon, Moshe; De Jong, Tom P V M

2015-04-01

The recently developed TOMAX-procedure restores unilateral genital sensation, improving sexual health in men with a low spinal lesion (LSL). It connects one dorsal nerve of the penis (DNP) to the intact ipsilateral ilioinguinal nerve. We proposed bilateral neurotization for full sensation of the glans but this entails cutting both DNPs, risking patients' erection/ejaculation ability. The objective was to select patients for a bilateral TOMAX-procedure by measuring remaining DNP function, and perform the first bilateral cases. In 30 LSL patients with no penile- but normal groin sensation selected for a unilateral TOMAX-procedure the integrity of the sacral-reflex-arc and DNP function was tested pre-operatively using bilateral needle electromyography (EMG)-bulbocavernosus reflex (BCR) measurements, and an interview about reflex erections (RE) ability. In 13 spina bifida- and 17 spinal cord injury patients [median age 29.5 years (range 13-59 years), spinal lesion T12 (incomplete) to sacral], seven (23%) patients reported RE, four (57%) with intact BCR, and of nine (30%) patients with intact BCR, four reported RE (44%). Even patients with a LSL and no penile sensation can have signs of remaining DNP function, but cutting both DNPs to restore full glans sensation in a bilateral TOMAX-procedure might interfere with their RE/ejaculation. To avoid this risk, we propose a selecting-protocol for a unilateral- or bilateral procedure using RE and BCR measurements. Using this protocol, three patients were bilaterally operated with promising preliminary results. Full sensation of the glans could lead to further improvement in sexual function. © 2014 Wiley Periodicals, Inc.

Phase II Study of High-Dose Photon/Proton Radiotherapy in the Management of Spine Sarcomas

DOE Office of Scientific and Technical Information (OSTI.GOV)

DeLaney, Thomas F.; Liebsch, Norbert J.; Pedlow, Francis X.

Purpose: Radiotherapy (XRT) for spine sarcomas is constrained by spinal cord, nerve, and viscera tolerance. Negative surgical margins are uncommon; hence, doses of {>=}66 Gy are recommended. A Phase II clinical trial evaluated high-dose photon/proton XRT for spine sarcomas. Methods and Materials: Eligible patients had nonmetastatic, thoracic, lumbar, and/or sacral spine/paraspinal sarcomas. Treatment included pre- and/or postoperative photon/proton XRT with or without radical resection; patients with osteosarcoma and Ewing's sarcoma received chemotherapy. Shrinking fields delivered 50.4 cobalt Gray equivalent (Gy RBE) to subclinical disease, 70.2 Gy RBE to microscopic disease in the tumor bed, and 77.4 Gy RBE to grossmore » disease at 1.8 Gy RBE qd. Doses were reduced for radiosensitive histologies, concurrent chemoradiation, or when diabetes or autoimmune disease present. Spinal cord dose was limited to 63/54 Gy RBE to surface/center. Intraoperative boost doses of 7.5 to 10 Gy could be given by dural plaque. Results: A total of 50 patients (29 chordoma, 14 chondrosarcoma, 7 other) underwent gross total (n = 25) or subtotal (n = 12) resection or biopsy (n = 13). With 48 month median follow-up, 5-year actuarial local control, recurrence-free survival, and overall survival are: 78%, 63%, and 87% respectively. Two of 36 (5.6%) patients treated for primary versus 7/14 (50%) for recurrent tumor developed local recurrence (p < 0.001). Five patients developed late radiation-associated complications; no myelopathy developed but three sacral neuropathies appeared after 77.12 to 77.4 Gy RBE. Conclusions: Local control with this treatment is high in patients radiated at the time of primary presentation. Spinal cord dose constraints appear to be safe. Sacral nerves receiving 77.12-77.4 Gy RBE are at risk for late toxicity.« less

An Unusual Case Report of Bertolotti's Syndrome: Extraforaminal Stenosis and L5 Unilateral Root Compression (Castellvi Type III an LSTV).

PubMed

Kapetanakis, Stylianos; Chaniotakis, Constantinos; Paraskevopoulos, Constantinos; Pavlidis, Pavlos

2017-01-01

Castellvi Type III lumbosacral transitional vertebrae (LSTV) is an unusual case of Bertolotti's syndrome (BS) due to extraforaminal stenosis, especially manifesting in elderly patients. We report a case of BS in a 62 years old Greek female. The signs of the clinical examination are low back pain, sciatica, hypoesthesia, and pain to the contribution of L5 nerve. Imaging techniques revealed an LSTV Type III a (complete sacralization between LSTV and sacrum). Despite the fact that LSTV is a congenital lesion, the clinical manifestation of BS may present in the elderly population. The accumulative effect of the gradual degeneration of intervertebral foramen (stenosis) may lead to the compression of extraforaminal portion of the nerve root.

[Alternative treatments for interstitial cystitis].

PubMed

Gamé, X; Bart, S; Castel-Lacanal, E; De Sèze, M; Karsenty, G; Labat, J-J; Rigaud, J; Scheiber-Nogueira, M C; Ruffion, A

2009-06-01

Interstitial cystitis is the first cause of bladder pain. In case of failure of the usual treatments, several other modalities have been proposed. These therapeutic modalities are posterior sacral root neuromodulation, posterior tibial nerve stimulation, vanilloid agent intravesical instillation, intradetrusor botulinum toxin injections and surgery. A certain efficiency of each of these treatments in the interstitial cystitis has been reported. However, the evaluation of these treatments is limited and the level of evidence is too low to propose these treatments in routine.

The importance of phrenic nerve preservation and its effect on long-term postoperative lung function after pneumonectomy.

PubMed

Kocher, Gregor J; Poulson, Jannie Lysgaard; Blichfeldt-Eckhardt, Morten Rune; Elle, Bo; Schmid, Ralph A; Licht, Peter B

2016-04-01

The importance of phrenic nerve preservation during pneumonectomy remains controversial. We previously demonstrated that preservation of the phrenic nerve in the immediate postoperative period preserved lung function by 3-5% but little is known about its long-term effects. We, therefore, decided to investigate the effect of temporary ipsilateral cervical phrenic nerve block on dynamic lung volumes in mid- to long-term pneumonectomy patients. We investigated 14 patients after a median of 9 years post pneumonectomy (range: 1-15 years). Lung function testing (spirometry) and fluoroscopic and/or sonographic assessment of diaphragmatic motion on the pneumonectomy side were performed before and after ultrasonographic-guided ipsilateral cervical phrenic nerve block by infiltration with lidocaine. Ipsilateral phrenic nerve block was successfully achieved in 12 patients (86%). In the remaining 2 patients, diaphragmatic motion was already paradoxical before the nerve block. We found no significant difference on dynamic lung function values (FEV1 'before' 1.39 ± 0.44 vs FEV1 'after' 1.38 ± 0.40; P = 0.81). Induction of a temporary diaphragmatic palsy did not significantly influence dynamic lung volumes in mid- to long-term pneumonectomy patients, suggesting that preservation of the phrenic nerve is of greater importance in the immediate postoperative period after pneumonectomy. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

An Implantable Neuroprosthetic Device to Normalize Bladder Function after SCI

DTIC Science & Technology

2013-10-01

we now used 2 separate cuff electrodes (one bipolar and one tripolar , i.e., the electrode #1 and #2 in Fig.1A) to deliver the low and high...Stim. A in Fig.1B) Page 5 and a high frequency (5-20 kHz, 0-11 V) biphasic square waveform (see Fig.1B) to the tripolar cuff electrodes #2 and...sacral spine. Two tripolar cuff electrodes were implanted bilaterally on the pudendal nerves in addition to one bipolar cuff electrode that was

An Unusual Case Report of Bertolotti’s Syndrome: Extraforaminal Stenosis and L5 Unilateral Root Compression (Castellvi Type III an LSTV)

PubMed Central

Kapetanakis, Stylianos; Chaniotakis, Constantinos; Paraskevopoulos, Constantinos; Pavlidis, Pavlos

2017-01-01

Introduction: Castellvi Type III lumbosacral transitional vertebrae (LSTV) is an unusual case of Bertolotti’s syndrome (BS) due to extraforaminal stenosis, especially manifesting in elderly patients. Case Report: We report a case of BS in a 62 years old Greek female. The signs of the clinical examination are low back pain, sciatica, hypoesthesia, and pain to the contribution of L5 nerve. Imaging techniques revealed an LSTV Type III a (complete sacralization between LSTV and sacrum). Conclusion: Despite the fact that LSTV is a congenital lesion, the clinical manifestation of BS may present in the elderly population. The accumulative effect of the gradual degeneration of intervertebral foramen (stenosis) may lead to the compression of extraforaminal portion of the nerve root. PMID:29051870

Clinical results of sacral neuromodulation for chronic voiding dysfunction using unilateral sacral foramen electrodes.

PubMed

Weil, E H; Ruiz-Cerdá, J L; Eerdmans, P H; Janknegt, R A; Van Kerrebroeck, P E

1998-01-01

The aim of this study was to determine the long-term clinical efficacy and complications of neuromodulation with a unilateral sacral foramen electrode in 36 patients with chronic voiding dysfunction. Following a positive effect of a percutaneous nerve evaluation test, patients underwent open surgery. A permanent electrode was implanted in 24 patients with urge incontinence, in 6 with urgency-frequency syndrome, and in 6 with nonobstructive urinary retention. After an average follow-up period of 37.8 months, 19 patients (52.8%) continue to benefit from the neuromodulation with a significant improvement of symptoms and urodynamic parameters. The median duration of the therapeutic effect for the total study population was longer than 60 months. No significant difference in the median duration of therapeutic effect with regard to sex, the type of voiding disorder, or the implant pulse generator was found. However, in patients with previous psychological disorders the median duration of therapeutic effect was only 12 months (P = 0.008). Complications were mild. In the group of patients in whom the therapeutic effect remains, 37 reoperations have had to be performed. We conclude that although reoperations were needed to overcome technical problems, patients can achieve lasting symptomatic improvement. Since technical changes in the equipment have reduced the number of complications, even better results can be expected in terms of the reoperation rate.

[Sacral neuromodulation in urology - development and current status].

PubMed

Schwalenberg, T; Stolzenburg, J-U; Kriegel, C; Gonsior, A

2012-01-01

Sacral neuromodulation (SNM) in urology is employed to treat refractory lower urinary tract dysfunction as well as chronic pelvic pain. Electrical stimulation of the sacral afferents (S2 - S4) causes activation and conditioning of higher autonomic and somatic neural structures and thereby influences the efferents controlling the urinary bladder, the rectum and their related sphincter systems. It is therefore possible to treat overactivity as well as hypocontractility and functional bladder neck obstruction. SNM treatment is conducted biphasically. Initially, test electrodes are placed to evaluate changes in micturition and pain parameters. If, in this first phase - called peripheral nerve evaluation (PNE test) - sufficient improvements are observed, the patient progresses to phase two which involves implantation of the permanent electrodes and impulse generator system. In recent years, the "two stage approach" with initial implantation of the permanent electrodes has been favoured as it increases treatment success rates. Long-term success rates of SNM vary significantly in the literature (50 - 80 %) due to heterogeneous patient populations as well as improved surgical approaches. With the introduction of "tined lead electrodes" (2002), tissue damage is reduced to a minimum. Technical innovation, financial feasibility (reimbursed in Germany since 2004) and wider application, especially in otherwise therapy-refractory patients or complex dysfunctions of the pelvis, have established SNM as a potent treatment option in urology. © Georg Thieme Verlag KG Stuttgart · New York.

Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit.

PubMed

Armañanzas, Laura; Arroyo, Antonio; Ruiz-Tovar, Jaime; López, Alberto; Santos, Jair; Moya, Pedro; Gómez, María Amparo; Candela, Fernando; Calpena, Rafael

2015-01-01

Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service. We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011. We evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments. Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases. Copyright © 2013 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Long-term recurrence rate of pleomorphic adenoma and postoperative facial nerve paresis (in parotid surgery).

PubMed

Zernial, Oliver; Springer, Ingo N; Warnke, Patrick; Härle, Franz; Risick, Christian; Wiltfang, Jörg

2007-04-01

The purpose of this study was to evaluate recurrence rates and comorbidity in patients with pleomorphic adenomas of patients after superficial and total conservative parotidectomy. Localization of pleomorphic adenomas, age, sex distribution and facial nerve function of 73 patients were examined in this retrospective study. The recurrence rate could be determined in 43 of these patients. The interval between surgery and last recall varied between 2 and 20 years (median: 8.1 years). Most of the patients were female (67%) with a parotid pleomorphic adenoma. No recurrence was found regard less of whether a superficial or total conservative parotidectomy had been performed. Our data did show that the total conservative parotidectomy is associated with a higher incidence of temporary impaired facial nerve function, which was seen in 42% of this group. Temporary decreased nerve function after superficial parotidectomy was rare being apparent in only 16% of this group. A more radical procedure does not significantly lower the recurrence rate. We suggest that the indication for a total conservative parotidectomy in cases of superficial adenomas should be considered carefully.

Early extraction: a silver bullet to avoid nerve injury in lower third molar removal?

PubMed

Zhang, Q-B; Zhang, Z-Q

2012-10-01

This retrospective study evaluated the effects of early extraction of immature lower third molar on preventing complications, particularly nerve injury following lower third molar removal. Patients were grouped according to age and radiographic results: group A (518 patients, ≤23 years, immature teeth with apical foramen not closed); group B (532 patients, >23 years, mature teeth with closed apical foramen). Group A included 230 males and 288 females (average age 17 years). In group A, 808 lower mandibular third molars were extracted bilaterally in 290 and unilaterally in 228 patients; the incidence of complications was 2.48% (20/808) (all were temporary), the incidence of nerve injury was 0%. Group B included 250 males and 282 females (average age 39 years). In group B, 810 lower third molars were extracted bilaterally in 278 and unilaterally in 254 patients; the incidence of complications was 10% (81/810), the incidence of nerve injury was 1.6% (13/810). All complications were temporary, except two removals of permanent inferior alveolar nerve numbness (>6 months). In this study, early removal of the lower third molar was effective in avoiding some postoperative complications, especially nerve injury. Early extraction of lower third molar in youngsters is recommended following a team consultation. Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Retropharyngeal Contralateral C7 Nerve Transfer to the Lower Trunk for Brachial Plexus Birth Injury: Technique and Results.

PubMed

Vu, Anthony T; Sparkman, Darlene M; van Belle, Christopher J; Yakuboff, Kevin P; Schwentker, Ann R

2018-05-01

Brachial plexus birth injuries with multiple nerve root avulsions present a particularly difficult reconstructive challenge because of the limited availability of donor nerves. The contralateral C7 has been described for brachial plexus reconstruction in adults but has not been well-studied in the pediatric population. We present our technique and results for retropharyngeal contralateral C7 nerve transfer to the lower trunk for brachial plexus birth injury. We performed a retrospective review. Any child aged less than 2 years was included. Charts were analyzed for patient demographic data, operative variables, functional outcomes, complications, and length of follow-up. We had a total of 5 patients. Average nerve graft length was 3 cm. All patients had return of hand sensation to the ulnar nerve distribution as evidenced by a pinch test, unprompted use of the recipient limb without mirror movement, and an Active Movement Scale (AMS) of at least 2/7 for finger and thumb flexion; one patient had an AMS of 7/7 for finger and thumb flexion. Only one patient had return of ulnar intrinsic hand function with an AMS of 3/7. Two patients had temporary triceps weakness in the donor limb and one had clinically insignificant temporary phrenic nerve paresis. No complications were related to the retropharyngeal nerve dissection in any patient. Average follow-up was 3.3 years. The retropharyngeal contralateral C7 nerve transfer is a safe way to supply extra axons to the severely injured arm in brachial plexus birth injuries with no permanent donor limb deficits. Early functional recovery in these patients, with regard to hand function and sensation, is promising. Therapeutic V. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Primary MPNST in Childhood- A Rare Case Report

PubMed Central

Kudesia, Sandip; Bhardwaj, Aparna; Kishore, Sanjeev; Bahal, Neelima

2014-01-01

Malignant peripheral nerve sheath tumour usually occurs between 20-50 years of age, comprising about 5-10% of soft tissue sarcomas. Only 1.7% of them have been reported to occur in children < 5 months of age according to the literature. Here, we are describing 18 mnth old male child presented with a swelling in the lower back. MRI showed a sacrcoccygeal swelling extending to and communicating with CSF at lower sacral level. Birth history of the child was normal with normal apgar score. The histological diagnosis was malignant peripheral nerve sheath tumour. IHC showed focal positivity of GFAP and S100. Primary spinal MPNST in children are rarer. A careful neurological examination is warranted in children. Early diagnosis and referral to multidisciplinary team are important in ensuring the best diagnosis and optimal therapy in this young age. PMID:25584230

Extradural cold block for selective neurostimulation of the bladder: development of a new technique.

PubMed

Schumacher, S; Bross, S; Scheepe, J R; Seif, C; Jünemann, K P; Alken, P

1999-03-01

Cryotechnique for selective block of the urethral sphincter and simultaneous activation of the bladder was developed to achieve physiological micturition during sacral anterior root stimulation (SARS). In ten foxhounds SARS of S2 was carried out while extradurally both spinal nerves S2 were cooled down from positive 25C in a stepwise fashion until a sphincter block was observed. Subsequently, SARS of S2 was performed while the pudendal nerves were cooled down from + 15C. The effects of spinal and pudendal nerve cold block on the urethral sphincter and bladder during SARS and the recovery time were monitored by urodynamic investigation. A complete cold block of the urethral sphincter during spinal nerve cooling was achieved in all cases. During pudendal nerve cooling, the sphincter was completely blocked in two, and incompletely blocked in four dogs. Cold block temperature of the spinal nerves averaged +11.7C and of the pudendal nerves +6.2C. During SARS and spinal nerve cooling, an increase in intravesical pressure up to 13 cm. water was recognized, and recovery time was on average 6.6 minutes. Intravesical pressure remained unchanged during pudendal nerve cooling, with recovery time being less than 1 minute. The cold block was always reversible. Cryotechnique is an excellent method for selective and reversible block of the urethral sphincter during SARS to avoid detrusor-sphincter-dyssynergia. The application of cryotechnique in functional electrical stimulation leads to an improvement of quality of life in para- or tetraplegic patients because of selective nerve stimulation with optimization of micturition, standing, walking and grasping and does so without the necessity of surgical dorsal root rhizotomy.

SaFaRI: sacral nerve stimulation versus the FENIX magnetic sphincter augmentation for adult faecal incontinence: a randomised investigation.

PubMed

Williams, Annabelle E; Croft, Julie; Napp, Vicky; Corrigan, Neil; Brown, Julia M; Hulme, Claire; Brown, Steven R; Lodge, Jen; Protheroe, David; Jayne, David G

2016-02-01

Faecal incontinence is a physically, psychologically and socially disabling condition. NICE guidance (2007) recommends surgical intervention, including sacral nerve stimulation (SNS), after failed conservative therapies. The FENIX magnetic sphincter augmentation (MSA) device is a novel continence device consisting of a flexible band of interlinked titanium beads with magnetic cores that is placed around the anal canal to augment anal sphincter tone through passive attraction of the beads. Preliminary studies suggest the FENIX MSA is safe, but efficacy data is limited. Rigorous evaluation is required prior to widespread adoption. The SaFaRI trial is a National Institute of Health Research (NIHR) Health Technology Assessment (HTA)-funded UK multi-site, parallel group, randomised controlled, unblinded trial that will investigate the use of the FENIX MSA, as compared to SNS, for adult faecal incontinence resistant to conservative management. Twenty sites across the UK, experienced in the treatment of faecal incontinence, will recruit 350 patients randomised equally to receive either SNS or FENIX MSA. Participants will be followed-up at 2 weeks post-surgery and at 6, 12 and 18 months post-randomisation. The primary endpoint is success, as defined by device in use and ≥50 % improvement in the Cleveland Clinic Incontinence Score (CCIS) at 18 months post-randomisation. Secondary endpoints include complications, quality of life and cost effectiveness. SaFaRI will rigorously evaluate a new technology for faecal incontinence, the FENIX™ MSA, allowing its safe and controlled introduction into current clinical practice. These results will inform the future surgical management of adult faecal incontinence.

Minimally Invasive Treatment for a Sacral Tarlov Cyst Through Tubular Retractors.

PubMed

Del Castillo-Calcáneo, Juan D; Navarro-Ramírez, Rodrigo; Nakhla, Jonathan; Kim, Eliana; Härtl, Roger

2017-12-01

Tarlov cysts (TC) are focal dilations of arachnoid and dura mater of the spinal posterior nerve root sheath that appear as cystic lesions of the nerve roots typically in the lower spine, especially in the sacrum, which can cause radicular symptoms when they increase in size and compress the nerve roots. Different open procedures have been described to treat TCs, but no minimally invasive procedures have been described to effectively address this pathology. A 29-year-old woman presented with right lower extremity pain and weakness. A magnetic resonance imaging scan demonstrated a lumbosacral TC that protruded through the right L5-S1 foramina. Through a small laminotomy, cyst drainage followed by neck ligation using a Scanlan modified technique through tubular retractors was performed. The patient recovered full motor function within the first days postoperatively and showed no signs of relapse at 6-month follow-up. Minimally invasive spine surgery through tubular retractors can be safely performed for successful excision and ligation of TC using a Scanlan modified technique. Copyright © 2017 Elsevier Inc. All rights reserved.

Sacral neuromodulation for lower urinary tract dysfunction and impact on erectile function.

PubMed

Lombardi, Giuseppe; Mondaini, Nicola; Giubilei, Gianluca; Macchiarella, Angelo; Lecconi, Filippo; Del Popolo, Giulio

2008-09-01

The first sacral nerve stimulators were for urinary urgency incontinence, urgency-frequency, and nonobstructive urinary retention. Since then, observations have been made for benefits beyond voiding disorders. To evaluate if sacral neuromodulation (SNM) using the InterStim system (Medtronic Inc., Minneapolis, MN, USA) improves erectile function. From January 1999 to January 2007, 54 males, mean age 42.8, underwent a permanent SNM for lower urinary tract symptoms (LUTS). Pre-SNM only subjects with concomitant erectile impairment according to the five-item version of the International Index of Erectile Function (IIEF-5), with normal blood sexual hormonal status, and responding to an intracavernous injection test 10 microg were enrolled in our study. Three months after permanent implantation, the IIEF-5 was completed again. Those who benefited significantly in erectile function completed the IIEF-5 semiannually. A final checkup was performed in July 2007. A score of IIEF-5 equal to or higher than 25% compared to baseline indicated remarkable clinical enhancement. Presurgery, two patients were excluded. Overall, 22 subjects (42.3%) showed erectile impairment (14 were neurogenic). In the first visit post-SNM, five retentionists of neurogenic origin and two with overactive bladder syndrome of idiopathic origin achieved noticeable erectile improvement. Their median IIEF-5 score shifted from 14.6 to 22.2, and 15.5 to 22.5, respectively. During follow-up, two neurogenics lost the benefits concerning voiding and erection and recovered them after a new implant in the contralateral sacral S3 root. In the final visit, the seven responders reached an IIEF-5 score of at least 22. Our study showed a clinically important benefit of sexual function mainly for neurogenic retentionists. Future research should test SNM in a larger sample of subjects, exclusively with sexual dysfunctions, in order to better understand the mechanism of action of SNM on erectile function.

A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction.

PubMed

Monga, Ash K; Tracey, Michael R; Subbaroyan, Jeyakumar

2012-08-01

The aim of this manuscript was to provide a systematic literature review of clinical trial evidence for a range of electrical stimulation therapies in the treatment of lower urinary tract symptoms (LUTS). The databases MEDLINE, BIOSIS Previews, Inside Conferences, and EMBASE were searched. Original clinical studies with greater than 15 subjects were included. Seventy-three studies were included, representing implanted sacral nerve stimulation (SNS), percutaneous posterior tibial nerve stimulation (PTNS), and transcutaneous electrical stimulation (TENS) therapy modalities. Median mean reductions in incontinence episodes and voiding frequency were similar for implanted SNS and PTNS. However, long-term follow-up data to validate the sustained benefit of PTNS are lacking. Despite a substantial body of research devoted to SNS validation, it is not possible to definitively define the appropriate role of this therapy owing largely to study design flaws that inhibited rigorous intention to treat analyses for the majority of these studies.

Identification of the origin of adrenergic and cholinergic nerve fibers within the superior hypogastric plexus of the human fetus

PubMed Central

Zaitouna, Mazen; Alsaid, Bayan; Diallo, Djibril; Benoit, Gérard; Bessede, Thomas

2013-01-01

Nerve fibers contributing to the superior hypogastric plexus (SHP) and the hypogastric nerves (HN) are currently considered to comprise an adrenergic part of the autonomic nervous system located between vertebrae (T1 and L2), with cholinergic aspects originating from the second to fourth sacral spinal segments (S2, S3 and S4). The aim of this study was to identify the origin and the nature of the nerve fibers within the SHP and the HN, especially the cholinergic fibers, using computer-assisted anatomic dissection (CAAD). Serial histological sections were performed at the level of the lumbar spine and pelvis in five human fetuses between 14 and 30 weeks of gestation. Sections were treated with histological staining [hematoxylin-eosin (HE) and Masson's trichrome (TriM)] and with immunohistochemical methods to detect nerve fibers (anti-S100), adrenergic fibers (anti-TH), cholinergic fibers (anti-VAChT) and nitrergic fibers (anti-nNOS). The sections were then digitalized using a high-resolution scanner and the 3D images were reconstructed using winsurf software. These experiments revealed the coexistence of adrenergic and cholinergic fibers within the SHP and the HNs. One-third of these cholinergic fibers were nitrergic fibers [anti-VACHT (+)/anti-NOS (+)] and potentially pro-erectile, while the others were non-nitrergic [anti-VACHT (+)/anti-NOS (−)]. We found these cholinergic fibers arose from the lumbar nerve roots. This study described the nature of the SHP nerve fibers which gives a better understanding of the urinary and sexual dysfunctions after surgical injuries. PMID:23668336

Diplopia after inferior alveolar nerve block: case report and related physiology.

PubMed

You, Tae Min

2015-06-01

Although inferior alveolar nerve block is one of the most common procedures performed at dental clinics, complications or adverse effects can still occur. On rare occasions, ocular disturbances, such as diplopia, blurred vision, amaurosis, mydriasis, abnormal pupillary light reflex, retrobulbar pain, miosis, and enophthalmos, have also been reported after maxillary and mandibular anesthesia. Generally, these symptoms are temporary but they can be rather distressing to both patients and dental practitioners. Herein, we describe a case of diplopia caused by routine inferior alveolar nerve anesthesia, its related physiology, and management.

Diplopia after inferior alveolar nerve block: case report and related physiology

PubMed Central

2015-01-01

Although inferior alveolar nerve block is one of the most common procedures performed at dental clinics, complications or adverse effects can still occur. On rare occasions, ocular disturbances, such as diplopia, blurred vision, amaurosis, mydriasis, abnormal pupillary light reflex, retrobulbar pain, miosis, and enophthalmos, have also been reported after maxillary and mandibular anesthesia. Generally, these symptoms are temporary but they can be rather distressing to both patients and dental practitioners. Herein, we describe a case of diplopia caused by routine inferior alveolar nerve anesthesia, its related physiology, and management. PMID:28879264

Persistent L5 lumbosacral radiculopathy caused by lumbosacral trunk schwannoma

PubMed Central

Sharifi, Guive; Jahanbakhshi, Amin

2017-01-01

Schwannomais, usually, benign tumor of nerve sheath that occurs evenly along the spinal cord. Intra-pelvic schwannoma is very rare entity that may arise from lumbosacral nerve roots or from sciatic nerve. Radicular pain of the lower limb as a presenting symptom of pelvic schwannoma is extremely rare. In the current report, the patient is presented with a right sided L5 radicular pain typical of lumbar discopathy. Interestingly, a herniated lumbar disc was noted on lumbosacral magnetic resonance imaging (MRI). In pre-operative studies a large pelvic mass was detected in the right pre-sacral area with solid and cystic components consistent with schwannoma. The patient underwent a low midline laparotomy to evacuate the retroperitoneal mass. Uniquely, we found the tumor to be arisen from lumbosacral trunk not from a root or peripheral nerve. Most cases with intra-pelvic schwannoma present so late with vague abdominal and pelvic discomfort or pain, low back pain, urinary and bowel symptoms because of compressive effect of the tumor, or incidentally following gynecologic work-ups; So, these patients are mostly referred to gynecologists and urologists. A neurosurgeon should have a high degree of suspicion to diagnose such an entity among his or her patients presented with pains typical for discopathy. PMID:28413533

Effect of phrenic nerve palsy on early postoperative lung function after pneumonectomy: a prospective study.

PubMed

Kocher, Gregor J; Mauss, Karl; Carboni, Giovanni L; Hoksch, Beatrix; Kuster, Roland; Ott, Sebastian R; Schmid, Ralph A

2013-12-01

The issue of phrenic nerve preservation during pneumonectomy is still an unanswered question. So far, its direct effect on immediate postoperative pulmonary lung function has never been evaluated in a prospective trial. We conducted a prospective crossover study including 10 patients undergoing pneumonectomy for lung cancer between July 2011 and July 2012. After written informed consent, all consecutive patients who agreed to take part in the study and in whom preservation of the phrenic nerve during operation was possible, were included in the study. Upon completion of lung resection, a catheter was placed in the proximal paraphrenic tissue on the pericardial surface. After an initial phase of recovery of 5 days all patients underwent ultrasonographic assessment of diaphragmatic motion followed by lung function testing with and without induced phrenic nerve palsy. The controlled, temporary paralysis of the ipsilateral hemidiaphragm was achieved by local administration of lidocaine 1% at a rate of 3 mL/h (30 mg/h) via the above-mentioned catheter. Temporary phrenic nerve palsy was accomplished in all but 1 patient with suspected catheter dislocation. Spirometry showed a significant decrease in dynamic lung volumes (forced expiratory volume in 1 second and forced vital capacity; p < 0.05) with the paralyzed hemidiaphragm. Blood oxygen saturation levels did not change significantly. Our results show that phrenic nerve palsy causes a significant impairment of dynamic lung volumes during the early postoperative period after pneumonectomy. Therefore, in these already compromised patients, intraoperative phrenic nerve injury should be avoided whenever possible. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Retrospective review of the efficacy and safety of repeated pulsed and continuous radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain.

PubMed

Nagda, Jyotsna V; Davis, Craig W; Bajwa, Zahid H; Simopoulos, Thomas T

2011-01-01

Chronic lumbosacral radicular pain is a common source of radiating leg pain seen in pain management patients. These patients are frequently managed conservatively with multiple modalities including medications, physical therapy, and epidural steroid injections. Radiofrequency has been used to treat chronic radicular pain for over 30 years; however, there is a paucity of literature about the safety and efficacy of repeat radiofrequency lesioning. To determine the safety, success rate, and duration of pain relief of repeat pulsed radiofrequency (PRF) and continuous radiofrequency (CRF) lesioning of the dorsal root ganglion (DRG)/ sacral segmental nerves (SN) in patients with chronic lumbosacral radicular pain. Retrospective chart review Outpatient multidisciplinary pain center Medical record review of patients who were treated with pulsed and continuous radiofrequency lesioning of the lumbar dorsal root ganglia and segmental nerves and who reported initial success were evaluated for recurrence of pain and repeat radiofrequency treatment. Responses to subsequent treatments were compared to initial treatments for success rates, average duration of relief, and adverse neurologic side-effects. Retrospective chart review without a control group. Twenty-six women and 24 men were identified who received 50% pain relief or better after PRF and CRF of the lumbar DRG/ sacral SN for lumbosacral radicular pain. The mean age was 62 years (range, 25-86). The mean duration of relief for the 40 patients who had 2 treatments was 4.7 months (range 0-24; Se [standard error] 0.74). Twenty-eight patients had 3 treatments with an average duration of relief of 4.5 months (range 0-19 months; Se 0.74). Twenty patients had 4 treatments with a mean duration of relief of 4.4 months (range 0.5-18; Se 0.95) and 18 patients who had 5 or more treatments received an average duration of relief of 4.3 months (range 0.5-18; Se 1.03). The average duration of relief and success frequency remained constant after each subsequent radiofrequency treatment. Of the 50 total patients, there was only 1 reported complication, specifically, transient thigh numbness which resolved after one week. Repeated pulsed and continuous radiofrequency ablation of the lumbar dorsal root ganglion/segmental nerve shows promise to be a safe and effective long-term palliative management for lumbosacral radicular pain in some patients.

Autistic spectrum disorder, epilepsy, and vagus nerve stimulation.

PubMed

Hull, Mariam Mettry; Madhavan, Deepak; Zaroff, Charles M

2015-08-01

In individuals with a comorbid autistic spectrum disorder and medically refractory epilepsy, vagus nerve stimulation may offer the potential of seizure control and a positive behavioral side effect profile. We aimed to examine the behavioral side effect profile using longitudinal and quantitative data and review the potential mechanisms behind behavioral changes. We present a case report of a 10-year-old boy with autistic spectrum disorder and epilepsy, who underwent vagus nerve stimulation subsequent to unsuccessful treatment with antiepileptic medication. Following vagus nerve stimulation implantation, initial, if temporary, improvement was observed in seizure control. Modest improvements were also observed in behavior and development, improvements which were observed independent of seizure control. Vagus nerve stimulation in autistic spectrum disorder is associated with modest behavioral improvement, with unidentified etiology, although several candidates for this improvement are evident.

Long term safety of sacral nerve modulation in medicare beneficiaries.

PubMed

Chughtai, Bilal; Sedrakyan, Art; Isaacs, Abby; Lee, Richard; Te, Alexis; Kaplan, Steven

2015-09-01

Sacral nerve stimulation (SNS) is FDA approved as second-line therapy for both urinary and bowel control. However, there is limited evidence regarding long term safety. We determined adverse events associated with SNS among Medicare beneficiaries. We used the 5% national random sample of Medicare claims for 2001-2011 to identify patients. Patients who underwent SNS implantation were identified with Current Procedure Terminology (CPT-4) codes. We determined safety of SNS using analysis of complication occurrences on day of surgery and during 5 years following initial procedure. SAS v9.3 statistical package was used. One thousand four hundred seventy-four patients underwent treatment with SNS in the 5% national sample of Medicare patients within the time period. Representative of real-world patients undergoing SNS surgery, comorbidities included hypertension (69.3%), diabetes (29.4%), chronic pulmonary disease (25.5%), hypothyroidism (25.2%), and depression (22.7%). Few complications occurred on day of surgery. At 90 days, 3.2% of patients had bowel complications, 2.0% urological, 9.4% infectious, and 1.5% stroke. Overall, bowel, neurological health event occurrences were consistent with prior year rates, while infectious events decreased. Of 206 patients who were followed for at least 5 years, 17.3% had devices removed and 11.3% replaced, with 26.1% having at least one of those, leaving 73.9% with original devices. Urological, infectious, and bowel complication occurrences were low after SNS among Medicare beneficiaries with multiple comorbidities. There were infrequent serious complications like hemorrhage and stroke postoperatively. Although SNS appears safe in this high-risk population, a comprehensive registry will ensure continuous safety. © 2014 Wiley Periodicals, Inc.

Improved sexual and urinary function in women with sacral nerve stimulation.

PubMed

Gill, Bradley C; Swartz, Mia A; Firoozi, Farzeen; Rackley, Raymond R; Moore, Courtenay K; Goldman, Howard B; Vasavada, Sandip P

2011-01-01

  Urinary and sexual function improve following sacral nerve stimulation (SNS) for refractory overactive bladder. No significant associations between these changes have been found. Whether improvements in sexual function are independent of or secondary to improvements in urinary function remains unclear. The aim of this study was to analyze changes in urinary and sexual function in a homogeneous sample of patients undergoing SNS for urge urinary incontinence and subsequently identify associations between the two.   A prospective database was created. Enrollees underwent a full history and physical examination at the first office visit. Multiple-day voiding diaries with validated and investigator-designed questionnaires were administered at baseline and follow-up as standard implantation procedures and to assess changes in urinary and sexual function, respectively. Analyses were completed using data from patients who were sexually active at baseline and follow-up.   Statistically significant improvements in urinary and sexual function occurred according to multiple metrics. Patient global impression scales categorized all patients' urinary conditions as improved, with most being less severe. Validated urinary symptom and quality of life scores improved significantly. After treatment, most patients were incontinent less often with sexual activity and felt less restricted from sexual activity by fear of incontinence. Validated quantification of sexual function demonstrated significant improvements in overall sexual function, arousal, and satisfaction. No significant associations between changes in urinary and sexual function were noted; however, trends appeared to exist between the two.   Improved sexual function was not significantly associated with improved urinary function after SNS despite apparent trends between the two. Larger samples are required to definitively demonstrate this conclusion. © 2011 International Neuromodulation Society.

Spinopelvic dissociation: multidetector computed tomographic evaluation of fracture patterns and associated injuries at a single level 1 trauma center.

PubMed

Gupta, Pushpender; Barnwell, Jonathan C; Lenchik, Leon; Wuertzer, Scott D; Miller, Anna N

2016-06-01

The objective of the present study is to evaluate multidetector computed tomographic (MDCT) fracture patterns and associated injuries in patients with spinopelvic dissociation (SPD). Our institutional trauma registry database was reviewed from Jan. 1, 2006, to Sept. 30, 2012, specifically evaluating patients with sacral fractures. MDCT scans of patients with sacral fractures were reviewed to determine the presence of SPD. SPD cases were characterized into the following fracture patterns: U-shaped, Y-shaped, T-shaped, H-shaped, and burst. The following MDCT features were recorded: level of the horizontal fracture, location of vertical fracture, kyphosis between major fracture fragments, displacement of fracture fragment, narrowing of central spinal canal, narrowing of neural foramina, and extension into sacroiliac joints. Quantitative evaluation of the sacral fractures was performed in accordance with the consensus statement by the Spine Trauma Study Group. Medical records were reviewed to determine associated pelvic and non-pelvic fractures, bladder and bowel injuries, nerve injuries, and type of surgical intervention. Twenty-one patients had SPD, of whom 13 were men and eight were women. Mean age was 41.8 years (range 18.8 to 87.7). Five fractures (24 %) were U-shaped, six (29 %) H-shaped, four (19 %) Y-shaped, and six (29 %) burst. Nine patients (43 %) had central canal narrowing, and 19 (90 %) had neural foramina narrowing. Eleven patients (52 %) had kyphotic angulation between major fracture fragments, and seven patients (33 %) had either anterior (24 %) or posterior (10 %) displacement of the proximal fracture fragment. Fourteen patients (67 %) had associated pelvic fractures, and 20 (95 %) had associated non-pelvic fractures. Two patients (10 %) had associated urethral injuries, and one (5 %) had an associated colon injury. Seven patients (33 %) had associated nerve injuries. Six patients (29 %) had surgical fixation while 15 (71 %) were managed non-operatively. On trauma MDCT examinations, patients with SPD have characteristic fracture patterns. It is important to differentiate SPD from other pelvic ring injuries due to high rate of associated injuries. Although all SPD injuries are unstable and need fixation, the decision for operative management in an individual patient depends on the systemic injury pattern, specific fracture pattern, and the ability to attain stable screw fixation.

Recovery of nerve injury-induced alexia for Braille using forearm anaesthesia.

PubMed

Björkman, Anders; Rosén, Birgitta; Lundborg, Göran

2008-04-16

Nerve injuries in the upper extremity may severely affect hand function. Cutaneous forearm anaesthesia has been shown to improve hand sensation in nerve-injured patients. A blind man who lost his Braille reading capability after an axillary plexus injury was treated with temporary cutaneous forearm anaesthesia. After treatment sensory functions of the hand improved and the patient regained his Braille reading capability. The mechanism behind the improvement is likely unmasking of inhibited or silent neurons, but after repeated treatment sessions at increasing intervals the improvement has remained at 1-year follow-up, implying a structural change in the somatosensory cortex.

The Effect of Offloading Heels on Sacral Pressure.

PubMed

Al-Majid, Sadeeka; Vuncanon, Barbara; Carlson, Nika; Rakovski, Cyril

2017-09-01

Offloading a patient's heels during supine surgical procedures is a common practice to prevent heel pressure injuries. This practice may increase sacral pressure and jeopardize sacral skin integrity, but prophylactic dressings may help protect sacral skin. The purpose of this study was to examine the effects of offloading the heels and of multilayered silicone foam dressings on sacral pressure. We measured the sacral pressure of 50 healthy volunteers using a pressure-mapping system under four conditions: heels not offloaded and sacral dressing applied, heels offloaded and dressing applied, heels not offloaded and no dressing, and heels offloaded and no dressing. We used linear mixed-effects modeling to compare the effects of these conditions on sacral pressure. Offloading the heels significantly increased sacral pressure (P < .001), whereas the dressing had no effect on sacral pressure (P = .49). Offloading a patient's heels may increase the risk of sacral pressure injuries. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Lingual nerve damage after mandibular third molar surgery: a randomized clinical trial.

PubMed

Gomes, Ana Cláudia Amorim; Vasconcelos, Belmiro Cavalcanti do Egito; de Oliveira e Silva, Emanuel Dias; da Silva, Luiz Carlos Ferreira

2005-10-01

The objective of this study was to clinically evaluate the frequency, type, and risk factors for lingual nerve damage after mandibular third molar surgery with reference to lingual flap retraction. A total of fifty-five patients referred for bilateral mandibular third molar removal were included in this study. Each patient was randomly allotted to have the procedure performed on 1 side (experimental group) with lingual flap retraction. On the opposite side (control group), the same procedure was performed without lingual flap retraction. Lingual nerve damage occurred in 9.1% in the experimental group in which lingual flap retraction was performed. In the control group, damage to the lingual nerve was not observed. The difference was statistically significant (P <.001) as measured by the Cochran test. Lingual nerve retraction represented a risk factor to temporary lingual nerve damage during mandibular third molar surgery.

Prevalence of extraforaminal nerve root compression below lumbosacral transitional vertebrae.

PubMed

Porter, Neil A; Lalam, Radhesh K; Tins, Bernhard J; Tyrrell, Prudencia N M; Singh, Jaspreet; Cassar-Pullicino, Victor N

2014-01-01

Although pathology at the first mobile segment above a lumbosacral transitional vertebra (LSTV) is a known source of spinal symptoms, nerve root compression below an LSTV, has only sporadically been reported. Our objective was to assess the prevalence of nerve root entrapment below an LSTV, review the causes of entrapment, and correlate with presenting symptoms. A retrospective review of MR and CT examinations of the lumbar spine was performed over a 5.5-year period in which the words "transitional vertebra" were mentioned in the report. Nerve root compression below an LSTV was assessed as well as the subtype of transitional vertebra. Correlation with clinical symptoms at referral was made. MR and CT examinations were also reviewed to exclude any other cause of symptoms above the LSTV. One hundred seventy-four patients were included in the study. Neural compression by new bone formation below an LSTV was demonstrated in 23 patients (13%). In all of these patients, there was a pseudarthrosis present on the side of compression due to partial sacralization with incomplete fusion. In three of these patients (13%), there was symptomatic correlation with no other cause of radiculopathy demonstrated. A further 13 patients (57%) had correlating symptoms that may in part be attributable to compression below an LSTV. Nerve root compression below an LSTV occurs with a prevalence of 13% and can be symptomatic in up to 70% of these patients. This region should therefore be carefully assessed in all symptomatic patients with an LSTV.

Parathyroid gland removal

MedlinePlus

... nerves going to the muscles that move your vocal cords. You may have a hoarse or weaker voice which could be temporary or permanent. Difficulty breathing. This is very rare and almost always goes away several weeks or months after surgery.

Anatomic parameters of the sacral lamina for osteosynthesis in transverse sacral fractures.

PubMed

Katsuura, Yoshihiro; Lorenz, Eileen; Gardner, Warren

2018-05-01

To analyze the morphometric parameters of the dorsal sacral lamina and pedicles to determine if there is adequate bony architecture to support plate osteosynthesis. Two reviewers performed measurements on 98 randomly selected high-resolution CT scans of the pelvis to quantify the bony anatomy of the sacral lamina. Measurements included the depths of the lamina at each sacral level, the trajectory and depth of the sacral pedicles from the sacral lamina, and the width of the sacral canal. A bone mineral density analysis was performed on the sacral lamina using Hounsfield units (HU) and compared to the L1 and S1 vertebral bodies. The sacral lamina were found to form peaks and troughs which we refered to as major and minor sections. On average, the thickness was > 4 mm at all major screw starting points, indicating adequate geometry for screw fixation. The sacral pedicle depths were 27, 18, 16, and 14 mm at S2-S5, respectively. The average angulation from midline of this screw path directed laterally to avoid the sacral canal was 20°, 17°, 8°, and - 8° for the S2-5 pedicles, respectively. Average sacral canal diameter was 11 mm for S2 and 8 mm for S3-5. The sacral lamina had an average bone mineral density of 635 HU, which was significantly different from the density of the L5 (220 HU) and S1 (165 HU) vertebral bodies (p < 0.005). This morphometric data was used to pilot a new plating technique. The sacral lamina offers a novel target for screw fixation and meets the basic geometric and compositional criteria for screw purchase. To our knowledge, this study represents the first morphometric analysis performed on the sacral lamina and pedicles for plate application.

Faecal incontinence: Current knowledges and perspectives

PubMed Central

Benezech, Alban; Bouvier, Michel; Vitton, Véronique

2016-01-01

Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools. PMID:26909229

Periocular Reconstruction in Patients with Facial Paralysis.

PubMed

Joseph, Shannon S; Joseph, Andrew W; Douglas, Raymond S; Massry, Guy G

2016-04-01

Facial paralysis can result in serious ocular consequences. All patients with orbicularis oculi weakness in the setting of facial nerve injury should undergo a thorough ophthalmologic evaluation. The main goal of management in these patients is to protect the ocular surface and preserve visual function. Patients with expected recovery of facial nerve function may only require temporary and conservative measures to protect the ocular surface. Patients with prolonged or unlikely recovery of facial nerve function benefit from surgical rehabilitation of the periorbital complex. Current reconstructive procedures are most commonly intended to improve coverage of the eye but cannot restore blink. Copyright © 2016 Elsevier Inc. All rights reserved.

Pudendal nerve stimulation and block by a wireless-controlled implantable stimulator in cats.

PubMed

Yang, Guangning; Wang, Jicheng; Shen, Bing; Roppolo, James R; de Groat, William C; Tai, Changfeng

2014-07-01

The study aims to determine the functionality of a wireless-controlled implantable stimulator designed for stimulation and block of the pudendal nerve. In five cats under α-chloralose anesthesia, the stimulator was implanted underneath the skin on the left side in the lower back along the sacral spine. Two tripolar cuff electrodes were implanted bilaterally on the pudendal nerves in addition to one bipolar cuff electrode that was implanted on the left side central to the tripolar cuff electrode. The stimulator provided high-frequency (5-20 kHz) biphasic stimulation waveforms to the two tripolar electrodes and low-frequency (1-100 Hz) rectangular pulses to the bipolar electrode. Bladder and urethral pressures were measured to determine the effects of pudendal nerve stimulation (PNS) or block. The maximal (70-100 cmH2O) urethral pressure generated by 20-Hz PNS applied via the bipolar electrode was completely eliminated by the pudendal nerve block induced by the high-frequency stimulation (6-15 kHz, 6-10 V) applied via the two tripolar electrodes. In a partially filled bladder, 20-30 Hz PNS (2-8 V, 0.2 ms) but not 5 Hz stimulation applied via the bipolar electrode elicited a large sustained bladder contraction (45.9 ± 13.4 to 52.0 ± 22 cmH2O). During cystometry, the 5 Hz PNS significantly (p < 0.05) increased bladder capacity to 176.5 ± 27.1% of control capacity. The wireless-controlled implantable stimulator successfully generated the required waveforms for stimulation and block of pudendal nerve, which will be useful for restoring bladder functions after spinal cord injury. © 2013 International Neuromodulation Society.

Relationship of the lumbar plexus branches to the lumbar spine: anatomical study with application to lateral approaches.

PubMed

Tubbs, Richard Isaiah; Gabel, Brandon; Jeyamohan, Shiveindra; Moisi, Marc; Chapman, Jens R; Hanscom, R David; Loukas, Marios; Oskouian, Rod J; Tubbs, Richard Shane

2017-07-01

Injuries to the lumbar plexus during lateral approaches to the spine are not uncommon and may result in permanent deficits. However, the literature contains few studies that provide landmarks for avoiding the branches of the lumbar plexus. The present anatomical study was performed to elucidate the course of these nerves in relation to lateral approaches to the lumbar spine. This is a quantitative anatomical cadaveric study. The lumbar plexus and its branches were dissected on 12 cadaveric sides. Metal wires were laid on the nerves along their paths on the posterior abdominal wall. Fluoroscopy was performed in the anteroposterior and lateral positions. The relationships between regional bony landmarks and the branches of the lumbar plexus were observed. When viewed laterally, the greatest concentration of nerves occurred from the posteroinferior aspect of L4, inferior along the posterior one-third of the body of L5, then at the level of the sacral promontory. On the basis of our study, approaches to the anterior two-thirds of the L4 vertebra and anterior third of L5 will result in the lowest chance of lumbar plexus nerve injury. In addition, lateral muscle dissection through the psoas major should be in a superior to inferior direction in order to minimize nerve injury. Laterally, the widest corridor between branches in the abdominal wall was between the subcostal and iliohypogastric nerves. The findings of our cadaveric study provide surgeons who approach the lateral lumbar spine with data that could decrease injuries to the branches of the lumbar plexus, thus lessening patient morbidity. Copyright © 2017 Elsevier Inc. All rights reserved.

Sacral Fractures and Associated Injuries

PubMed Central

Kurd, Mark F.; Schroeder, Gregory D.; Kepler, Christopher K.; Krieg, James C.; Holstein, Jörg H.; Bellabarba, Carlo; Firoozabadi, Reza; Oner, F. Cumhur; Kandziora, Frank; Dvorak, Marcel F.; Kleweno, Conor P.; Vialle, Luiz R.; Rajasekaran, S.; Schnake, Klause J.; Vaccaro, Alexander R.

2017-01-01

Study Design: Literature review. Objective: The aim of this review is to describe the injuries associated with sacral fractures and to analyze their impact on patient outcome. Methods: A comprehensive narrative review of the literature was performed to identify the injuries associated with sacral fractures. Results: Sacral fractures are uncommon injuries that result from high-energy trauma, and that, due to their rarity, are frequently underdiagnosed and mistreated. Only 5% of sacral fractures occur in isolation. Injuries most often associated with sacral fractures include neurologic injuries (present in up to 50% of sacral fractures), pelvic ring disruptions, hip and lumbar spine fractures, active pelvic/ abdominal bleeding and the presence of an open fracture or significant soft tissue injury. Diagnosis of pelvic ring fractures and fractures extending to the lumbar spine are key factors for the appropriate management of sacral fractures. Importantly, associated systemic (cranial, thoracic, and abdominopelvic) or musculoskeletal injuries should be promptly assessed and addressed. These associated injuries often dictate the management and eventual outcome of sacral fractures and, therefore, any treatment algorithm should take them into consideration. Conclusions: Sacral fractures are complex in nature and often associated with other often-missed injuries. This review summarizes the most relevant associated injuries in sacral fractures and discusses on their appropriate management. PMID:28989838

Temporary Mental Nerve Paresthesia Originating from Periapical Infection

PubMed Central

Genc Sen, Ozgur; Kaplan, Volkan

2015-01-01

Many systemic and local factors can cause paresthesia, and it is rarely caused by infections of dental origin. This report presents a case of mental nerve paresthesia caused by endodontic infection of a mandibular left second premolar. Resolution of the paresthesia began two weeks after conventional root canal treatment associated with antibiotic therapy and was completed in eight weeks. One year follow-up radiograph indicated complete healing of the radiolucent periapical lesion. The tooth was asymptomatic and functional. PMID:26345692

High-frequency ultrasound as an adjunct to neural electrophysiology: Evaluation and prognosis of Bell's palsy.

PubMed

Li, Shuo; Guo, Rui-Jun; Liang, Xiao-Ning; Wu, Yue; Cao, Wen; Zhang, Zhen-Ping; Zhao, Wei; Liang, Hai-Dong

2016-01-01

Bell's palsy is a form of temporary facial nerve paralysis that occurs primarily in young adults. Previously, various methods were used to assess outcomes in facial nerve disease. The aim of the present study was to characterize the main branches of the normal and abnormal facial nerve using high-frequency ultrasonography (HFUS). A total of 104 healthy volunteers, 40 patients with acute onset of Bell's palsy and 30 patients who underwent 3-month routine therapy for Bell's palsy disease were included in the study. The healthy volunteers and patients were selected for HFUS examination and VII nerve conduction. The results showed significant differences in nerve diameter, echogenicity, delitescence and amplitude in different groups. Statistically significant correlations were identified for severity grading in one of the experimental groups during HFUS examinations. In conclusion, HFUS as a complementary technique paired with neural electrophysiology may establish the normal values of facial nerve. Additionally, HFUS was beneficial in the process of evaluation and prognosis of Bell's palsy disease.

Transcutaneous Electrical Nerve Stimulation Combined with Oxybutynin is Superior to Monotherapy in Children with Urge Incontinence: A Randomized, Placebo Controlled Study.

PubMed

Borch, Luise; Hagstroem, Soeren; Kamperis, Konstantinos; Siggaard, C V; Rittig, Soeren

2017-08-01

We evaluated whether combination therapy with transcutaneous electrical nerve stimulation and oxybutynin results in a superior treatment response compared to either therapy alone in children with urge incontinence. In this placebo controlled study 66 children with a mean ± SD age of 7.3 ± 1.6 years who were diagnosed with urge incontinence were randomized to 3 treatment groups. Group 1 consisted of 22 children undergoing transcutaneous electrical nerve stimulation plus active oxybutynin administration. Group 2 included 21 children undergoing active transcutaneous electrical nerve stimulation plus placebo oxybutynin administration. Group 3 consisted of 23 children undergoing active oxybutynin administration plus placebo transcutaneous electrical nerve stimulation. The children received active or placebo transcutaneous electrical nerve stimulation over the sacral S2 to S3 outflow for 2 hours daily in combination with 5 mg active or placebo oxybutynin twice daily. The intervention period was 10 weeks. Primary outcome was number of wet days weekly. Secondary outcomes were severity of incontinence, frequency, maximum voided volume over expected bladder capacity for age, average voided volume over expected bladder capacity for age and visual analogue scale score. Combination therapy was superior to oxybutynin monotherapy, with an 83% greater chance of treatment response (p = 0.05). Combination therapy was also significantly more effective than transcutaneous electrical nerve stimulation monotherapy regarding reduced number of wet days weekly (mean difference -2.28, CI -4.06 to -0.49), severity of incontinence (-3.11, CI -5.98 to -0.23) and daily voiding frequency (-2.82, CI -4.48 to -1.17). Transcutaneous electrical nerve stimulation in combination with oxybutynin for childhood urge incontinence was superior to monotherapy consisting of transcutaneous electrical nerve stimulation or oxybutynin, although the latter only reached borderline statistical significance. Furthermore, transcutaneous electrical nerve stimulation was associated with a decreased risk of oxybutynin induced post-void residual urine greater than 20 ml. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Chronic monitoring of lower urinary tract activity via a sacral dorsal root ganglia interface

NASA Astrophysics Data System (ADS)

Khurram, Abeer; Ross, Shani E.; Sperry, Zachariah J.; Ouyang, Aileen; Stephan, Christopher; Jiman, Ahmad A.; Bruns, Tim M.

2017-06-01

Objective. Our goal is to develop an interface that integrates chronic monitoring of lower urinary tract (LUT) activity with stimulation of peripheral pathways. Approach. Penetrating microelectrodes were implanted in sacral dorsal root ganglia (DRG) of adult male felines. Peripheral electrodes were placed on or in the pudendal nerve, bladder neck and near the external urethral sphincter. Supra-pubic bladder catheters were implanted for saline infusion and pressure monitoring. Electrode and catheter leads were enclosed in an external housing on the back. Neural signals from microelectrodes and bladder pressure of sedated or awake-behaving felines were recorded under various test conditions in weekly sessions. Electrodes were also stimulated to drive activity. Main results. LUT single- and multi-unit activity was recorded for 4-11 weeks in four felines. As many as 18 unique bladder pressure single-units were identified in each experiment. Some channels consistently recorded bladder afferent activity for up to 41 d, and we tracked individual single-units for up to 23 d continuously. Distension-evoked and stimulation-driven (DRG and pudendal) bladder emptying was observed, during which LUT sensory activity was recorded. Significance. This chronic implant animal model allows for behavioral studies of LUT neurophysiology and will allow for continued development of a closed-loop neuroprosthesis for bladder control.

Radiosurgery and radiotherapy for sacral tumors.

PubMed

Gibbs, Iris C; Chang, Steven D

2003-08-15

Sacral tumors represent a small subset of spinal lesions and typically include chordomas, metastases, other primary bone tumors, and benign schwannomas. Resection is the standard treatment for many sacral tumors, but many types of sacral lesions have the potential for recurrence after excision. In these cases, adjuvant radiotherapy is often beneficial. Although conventional radiotherapy plays an important role in the management of spinal lesions, the radiation doses required for adequate local control of many sacral lesions generally exceed the tolerance doses of normal tissues, thus limiting its definitive role in the management of sacral tumors. Recent advances in the field of stereotactic radiosurgery have allowed precise targeting of the sacrum. In this report the authors review the use of these two forms of radiation treatment and their role in managing sacral tumors.

Latissimus dorsi free flap for coverage of sacral radiodermatitis in the ambulatory patient

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stark, D.; Tofield, J.J.; Terranova, W.

1987-07-01

Ambulatory patients with large sacral ulcers can represent extremely challenging coverage problems. Technical options become fewer when sacral ulcers are coupled with radiation dermatitis. Latissimus dorsi free flap transfer, with direct anastomoses to sacral vessels, is described in 2 patients.

The receptor tyrosine kinase RET regulates hindgut colonization by sacral neural crest cells.

PubMed

Delalande, Jean-Marie; Barlow, Amanda J; Thomas, Aaron J; Wallace, Adam S; Thapar, Nikhil; Erickson, Carol A; Burns, Alan J

2008-01-01

The enteric nervous system (ENS) is formed from vagal and sacral neural crest cells (NCC). Vagal NCC give rise to most of the ENS along the entire gut, whereas the contribution of sacral NCC is mainly limited to the hindgut. This, and data from heterotopic quail-chick grafting studies, suggests that vagal and sacral NCC have intrinsic differences in their ability to colonize the gut, and/or to respond to signalling cues within the gut environment. To better understand the molecular basis of these differences, we studied the expression of genes known to be essential for ENS formation, in sacral NCC within the chick hindgut. Our results demonstrate that, as in vagal NCC, Sox10, EdnrB, and Ret are expressed in sacral NCC within the gut. Since we did not detect a qualitative difference in expression of these ENS genes we performed DNA microarray analysis of vagal and sacral NCC. Of 11 key ENS genes examined from the total data set, Ret was the only gene identified as being highly differentially expressed, with a fourfold increase in expression in vagal versus sacral NCC. We also found that over-expression of RET in sacral NCC increased their ENS developmental potential such that larger numbers of cells entered the gut earlier in development, thus promoting the fate of sacral NCC towards that of vagal NCC.

Dexamethasone minimizes the risk of cranial nerve injury during CEA.

PubMed

Regina, Guido; Angiletta, Domenico; Impedovo, Giovanni; De Robertis, Giovanni; Fiorella, Marialuisa; Carratu', Maria Rosaria

2009-01-01

The incidence of cranial and cervical nerve injury during carotid endarterectomy (CEA) ranges from less than 7.6% to more than 50%. Lesions are mainly due to surgical maneuvers such as traction, compression, tissue electrocoagulation, clamping, and extensive dissections. The use of dexamethasone (DEX) and its beneficial effects in spinal cord injuries have already been described. We investigated whether DEX could also be beneficial to minimize the incidence of cranial and cervical nerve injury during CEA. To evaluate whether dexamethasone is able to reduce the incidence of cranial nerve injuries. From March 1999 through April 2006, 1126 patients undergoing CEA because of high-grade carotid stenosis were enrolled and randomized by predetermined randomization tables into two groups. The first group, "A", included 586 patients that all received an intravenous administration of dexamethasone following a therapeutic scheme. The second group, "B", included 540 control subjects that received the standard pre- and postoperative therapy. All patients were submitted to a deep cervical plexus block, eversion carotid endarterectomy, and selective shunting. Three days after the operation, an independent neurologist and otorhinolaryngologist evaluated the presence of cranial nerve deficits. All patients (group A and group B) showing nerve injuries continued the treatment (8 mg of dexamethasone once in the morning) for 7 days and were re-evaluated after 2 weeks, 30 days, and every 3 months for 1 year. Recovery time took from 2 weeks to 12 months, with a mean time of 3.6 months. The chi(2) test was used to compare the two groups and to check for statistical significance. The incidence of cranial nerve dysfunction was higher in group B and the statistical analysis showed a significant effect of dexamethasone in preventing the neurological damage (P = .0081). The incidence of temporary lesions was lower in group A and the chi(2) test yielded a P value of .006. No statistically significant differences were found when comparing the effect of dexamethasone in men and women. In addition, dexamethasone had no statistically significant effect on the incidence of permanent cranial nerve injuries. Finally, no adverse effect related to the administration of dexamethasone was observed. Perioperative administration of dexamethasone is effective in minimizing the incidence of temporary cranial nerve injuries during CEA.

Spinal cord stimulation (SCS) in conjunction with peripheral nerve field stimulation (PNfS) for the treatment of complex pain in failed back surgery syndrome (FBSS).

PubMed

Reverberi, Claudio; Dario, Alessandro; Barolat, Giancarlo

2013-01-01

Failed back surgery syndrome (FBSS) is a well-defined pathologic condition observed over many years. We have investigated the effect of spinal cord stimulation (SCS) with peripheral nerve field stimulation (PNfS) in eight patients with FBSS. The following parameters were collected and analyzed: The pain intensity score on a 0-10 numbering rating scale (NRS), the psychologic profile with Beck Depression Inventory (BDI), the pain quality with McGill Pain Questionnaire-short form (MGPQ-sf), the back pain with Oswestry scale score (OS), and the health general quality pattern with QualityMetric's SF-36v2(®) Health Survey. Eight patients with low back and radicular pain in FBSS are reported. The mean duration of pain was 6.7 months, and the mean NRS score was 9.5, BDI 28.8, MGPQ-sf 16.8, OS 44.5, and SF-36 score was 72.8. The average drug intake of opioids was 250 mg/day. In six patients, two octopolar leads were placed in epidural space at D7-D8 and D8-D9, in conjunction with two octopolar leads placed in lumbar-sacral subcutaneous space (Precision System, Boston Scientific, Valencia, CA, USA), and in two patients, a two tetrapolar leads was placed in epidural space at D8-D9 with two tetrapolar leads (Pisces Quad, Plus, Medtronic Inc., Minneapolis, MN, USA) placed in lumbar-sacral subcutaneous space (Restore Ultra, Medtronic Inc., Minneapolis, MN, USA). After one year mean of follow-up, the mean NRS score was 4, BDI 8, MGPQ-sf 5, OS 21, and the SF-36 score was increased at 108.5. The mean drug intake of opioids was decreased at 20 mg/day. The combination of SCS and PNfS, using the latest rechargeable systems, may be a valid therapeutic strategy in FBSS. © 2012 International Neuromodulation Society.

Patient characteristics and treatment outcome in functional anorectal pain.

PubMed

Atkin, Gary K; Suliman, Amna; Vaizey, Carolynne J

2011-07-01

Functional anorectal pain occurs in the absence of any clinical abnormality. It is common and disabling; it has previously been reported in only a few studies involving small patient numbers. This study aimed to report the clinical characteristics and treatment outcomes for patients with functional anorectal pain. Patient demographics, clinical history, and tests results for all referrals for anorectal physiological testing between 1997 and 2009 were prospectively recorded. For patients with functional anorectal pain, further information was gained from clinical notes. Clinical history, anorectal physiology, and radiological imaging data were recorded for all patients; treatment outcome was noted for patients treated and followed up at the present unit. One hundred seventy patients, 99 female, with a median age of 48 years (range, 18-86), were studied. Patients were classified as having chronic proctalgia (pain duration ≥20 min, 158 patients) or proctalgia fugax (pain duration <20 min, 12 patients). The pain was most commonly located in the anal canal (90%) and aggravated by defecation or sitting (66%). A third of patients had a history of psychological disturbance. Internal anal sphincter thickness correlated with resting anal pressures. Patients with proctalgia fugax had a higher internal anal sphincter thickness and resting pressure than patients with chronic proctalgia, whereas patients with a family history of similar symptoms were more likely to have proctalgia fugax and higher resting pressures and internal anal sphincter thickness compared with those without a family history of these symptoms. Patients referred for treatment underwent a range of interventions including biofeedback (29 patients, 17 improved), tricyclic antidepressants (26 patients, 10 improved), Botox injection (9 patients, 5 improved), and sacral nerve stimulation (3 patients, 2 improved). Biofeedback had the greatest treatment effect, especially in patients with defecatory dysfunction. Biofeedback is beneficial in the subset of patients with functional anorectal pain and difficulty with defecation. Tricyclic antidepressants, Botox, and sacral nerve stimulation may also have a role.

Complex sacral abscess 8 years after abdominal sacral colpopexy.

PubMed

Collins, Sarah A; Tulikangas, Paul K; LaSala, Christine A; Lind, Lawrence R

2011-08-01

Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period. A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh. Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

Diagnosis and treatment of posterior sacroiliac complex pain: a systematic review with comprehensive analysis of the published data.

PubMed

King, Wade; Ahmed, Shihab U; Baisden, Jamie; Patel, Nileshkumar; Kennedy, David J; Duszynski, Belinda; MacVicar, John

2015-02-01

To assess the evidence on the validity of sacral lateral branch blocks and the effectiveness of sacral lateral branch thermal radiofrequency neurotomy in managing sacroiliac complex pain. Systematic review with comprehensive analysis of all published data. Six reviewers searched the literature on sacral lateral branch interventions. Each assessed the methodologies of studies found and the quality of the evidence presented. The outcomes assessed were diagnostic validity and effectiveness of treatment for sacroiliac complex pain. The evidence found was appraised in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system of evaluating scientific evidence. The searches yielded two primary publications on sacral lateral branch blocks and 15 studies of the effectiveness of sacral lateral branch thermal radiofrequency neurotomy. One study showed multisite, multidepth sacral lateral branch blocks can anesthetize the posterior sacroiliac ligaments. Therapeutic studies show sacral lateral branch thermal radiofrequency neurotomy can relieve sacroiliac complex pain to some extent. The evidence of the validity of these blocks and the effectiveness of this treatment were rated as moderate in accordance with the GRADE system. The literature on sacral lateral branch interventions is sparse. One study demonstrates the face validity of multisite, multidepth sacral lateral branch blocks for diagnosis of posterior sacroiliac complex pain. Some evidence of moderate quality exists on therapeutic procedures, but it is insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy, and more research is required. Wiley Periodicals, Inc.

Neurovascular risks of sacral screws with bicortical purchase: an anatomical study.

PubMed

Ergur, Ipek; Akcali, Omer; Kiray, Amac; Kosay, Can; Tayefi, Hamid

2007-09-01

The aim of this cadaver study is to define the anatomic structures on anterior sacrum, which are under the risk of injury during bicortical screw application to the S1 and S2 pedicles. Thirty formaldehyde-preserved human male cadavers were studied. Posterior midline incision was performed, and soft tissues and muscles were dissected from the posterior part of the lumbosacral region. A 6 mm pedicle screw was inserted between the superior facet of S1 and the S1 foramen. The entry point of the S2 pedicle screw was located between S1 and S2 foramina. S1 and S2 screws were placed on both right and the left sides of all cadavers. Then, all cadavers were turned into supine position. All abdominal and pelvic organs were moved away and carefully observed for any injury. The tips of the sacral screws were marked and the relations with the anatomic structures were defined. The position of the sacral screws relative to the middle and lateral sacral arteries and veins, and the sacral sympathetic trunk were measured. There was no injury to the visceral organs. In four cases, S1 screw tip was in direct contact with middle sacral artery. In two cases, S1 screw tip was in direct contact with middle sacral vein. It was observed that the S1 screw tips were in close proximity to sacral sympathetic trunk on both right and the left sides. The tip of the S2 screw was in contact with middle sacral artery on the left side only in one case. It is found that the tip of the S2 screw was closely located with the middle sacral vein in two cases. The tip of the S2 pedicle screw was in contact with the sacral sympathetic trunk in eight cases on the right side and seven cases on the left side. Lateral sacral vein was also observed to be disturbed by the S1 and S2 screws. As a conclusion, anterior cortical penetration during sacral screw insertion carries a risk of neurovascular injury. The risk of sacral sympathetic trunk and minor vascular structures together with the major neurovascular structures and viscera should be kept in mind.

Management of OAB in those over age 65.

PubMed

Natalin, Ricardo; Lorenzetti, Fabio; Dambros, Miriam

2013-10-01

The International Continence Society (ICS) defines overactive bladder (OAB) as an association of symptoms including "urgency, with or without urge incontinence, usually with increased frequency and nocturia". This conditon has been associated with a decrease in quality of life and a higher related risk of overall health condition decrease, and is rising since its prevalence increases with age and the forecast for the world population estimates an increase of those over 65 years old. Aging alone can be considered a major risk factor for developing OAB symptoms that are considered multifactorial and due to body tissue and anatomic changes, lifestyle-associated factors, comorbidities and personal characteristics. The high prevalence of this condition and multiple etiology factors makes of its treatment a challenge-especially in the older population. A major concern over OAB treatment of elderly patients is the risk of cognitive side effects due to the pharmacologic treatment with anticholinergic drugs. First-line treatment for OAB symptoms are the use of pharmacologic therapy with antimuscarinic drugs, which has been proved to be effective in controlling urgency, urge incontinence episodes, incontinence episodes, and nocturia. The impact caused by this condition is significant regarding the economic and human costs associated bringing into attention the need of studying and reviewing this specific population. Conservative Management and Lifestyle Modifications: Behavioral therapy's aims are to reduce urinary frequency and urgency to an accepted level and to increase bladder outlet volume. It consists of actions to teach patients to improve and learn bladder control. Lifestyle modifications are a conjunct of daily activities that can be managed to have the lowest interference on the functioning of the urinary tract. Pharmacologic Therapy: There are various medications with antimuscarinic properties available for the treatment of OAB symptoms. The most commonly used are oxybutinin, tolterodine, solifenacin, darifenacin, fesosterodine and trospium. Second-line Therapy: OAB treatment accounts for some refractory to conventional treatment patients who will require alternative therapies to achieve improvement of symptoms as the use of intradetrusor injection of botulinum A toxin by binding to receptors on the membrane of cholinergic nerves causing temporary chemodenervation and consequent muscle relaxation. Neuromodulation is also an effective therapy that aims to achieve inhibition of detrusor activity by continuous neural stimulation through peripheral nerves as the use of the tibial nerve or central as it is performed by direct spine stimulation on sacral roots through the implantation of an automated generator. In conclusion, evidence from the literature has shown that antimuscarinic treatment of OAB in the elderly population is safe and effective in improving symptoms and patient's quality of life. Managing OAB symptoms in this population is a great challenge. An optimal therapeutic approach to treat should involve medical treatment with drug and behavioral therapy in addition to lifestyle advice.

Postural headache in a patient with Marfan's syndrome.

PubMed

Ferrante, E; Citterio, A; Savino, A; Santalucia, P

2003-09-01

A 26-year-old man with Marfan's syndrome had postural headache. Brain MRI with gadolinium showed diffuse pachymeningeal enhancement. MRI myelography revealed bilateral multiple large meningeal diverticula at sacral nerve roots level. He was suspected to have spontaneous intracranial hypotension syndrome. Eight days later headache improved with bed rest and hydration. One month after the onset he was asymptomatic and 3 months later brain MRI showed no evidence of diffuse pachymeningeal enhancement. The 1-year follow-up revealed no neurological abnormalities. The intracranial hypotension syndrome likely resulted from a CSF leak from one of the meningeal diverticula. In conclusion patients with spinal meningeal diverticula (frequently seen in Marfan's syndrome) might be at increased risk of developing CSF leaks, possibly secondary to Valsalva maneuver or minor unrecognized trauma.

Targeted fascicular biopsy of the sciatic nerve and its major branches: rationale and operative technique.

PubMed

Capek, Stepan; Amrami, Kimberly K; Dyck, P James B; Spinner, Robert J

2015-09-01

OBJECT Nerve biopsy is typically performed in distal, noncritical sensory nerves without using imaging to target the more involved regions. The yield of these procedures rarely achieves more than 50%. In selected cases where preoperative evaluation points toward a more localized (usually a more proximal) process, targeted biopsy would likely capture the disease. Synthesis of data obtained from clinical examination, electrophysiological testing, and MRI allows biopsy of a portion of the major mixed nerves safely and efficiently. Herein, experiences with the sciatic nerve are reported and a description of the operative technique is provided. METHODS All cases of sciatic nerve biopsy performed between 2000 and 2014 were reviewed. Only cases of fascicular nerve biopsy approached from the buttock or the posterior aspect of the thigh were included. Demographic data, clinical presentation, and the presence of percussion tenderness for each patient were recorded. Reviewed studies included electrodiagnostic tests and imaging. Previous nerve and muscle biopsies were noted. All details of the procedure, final pathology, and its treatment implications were recorded. The complication rate was carefully assessed for temporary as well as permanent complications. RESULTS One hundred twelve cases (63 men and 49 women) of sciatic nerve biopsy were performed. Mean patient age was 46.4 years. Seventy-seven (68.8%) patients presented with single lower-extremity symptoms, 16 (14.3%) with bilateral lower-extremity symptoms, and 19 (17%) with generalized symptoms. No patient had normal findings on physical examination. All patients underwent electrodiagnostic studies, the findings of which were abnormal in 110 (98.2%) patients. MRI was available for all patients and was read as pathological in 111 (99.1%). The overall diagnostic yield of biopsy was 84.8% (n = 95). The pathological diagnoses included inflammatory demyelination, perineurioma, nonspecific inflammatory changes, neurolymphomatosis, amyloidosis, prostate cancer, injury neuroma, neuromuscular choristoma, sarcoidosis, vasculitis, hemangiomatosis, arteriovenous malformation, fibrolipomatous hamartoma (lipomatosis of nerve), and cervical adenocarcinoma. The series included 11 (9.9%) temporary and 5 (4.5%) permanent complications: 3 patients (2.7%) reported permanent numbness in the peroneal division distribution, and 2 patients (1.8%) were diagnosed with neuromuscular choristoma that developed desmoid tumor at the biopsy site 3 and 8 years later. CONCLUSIONS Targeted fascicular biopsy of the sciatic nerve is a safe and efficient diagnostic procedure, and in highly selected cases can be offered as the initial procedure over distal cutaneous nerve biopsy. Diagnoses were very diverse and included entities considered very rare. Even for the more prevalent diagnoses, the biopsy technique allowed a more targeted approach with a higher diagnostic yield and justification for more aggressive treatment. In this series, new radiological patterns of some entities were identified, which could be biopsied less frequently.

A study on difference and importance of sacral slope and pelvic sacral angle that affect lumbar curvature.

PubMed

Choi, Seyoung; Lee, Minsun; Kwon, Byongan

2014-01-01

Individual pelvic sacral angle was measured, compared and analyzed for the 6 male and female adults who were diagnosed with lumbar spinal stenosis, foraminal stenosis and mild spondylolisthesis in accordance with spinal parameters, pelvic parameters and occlusion state of sacroiliac joint presented by the author of this thesis based on the fact that the degree of lumbar excessive lordosis that was one of the causes for lumbar pain was determined by sacral slope. The measured values were compared with the standard values of the average normal range from 20 s to 40 s of normal Koreans stated in the study on the change in lumbar lordosis angle, lumbosacral angle and sacral slope in accordance with the age by Oh et al. [5] and sacral slope and pelvic sacral slope of each individual of the subjects for measurement were compared. Comparing the difference between the two tilt angles possessed by an individual is a comparison to determine how much the sacroiliac joint connecting pelvis and sacral vertebrae compensated and corrected the sacral vertebrae slope by pelvic tilt under the condition of synarthrodial joint.Under the condition that the location conforming to the line in which the sagittal line of gravity connects with pelvic ASIS and pubic pubic tuberele is the neutral location of pelvic tilt, sacral slope being greater than pelvic sacral slope means pelvic anterior tilting, whereas sacral slope being smaller than pelvic sacral slope means pelvic posterior tilting. On that account, male B, female A and female C had a pelvic posterior tilting of 16 degrees, 1 degree and 5 degrees respectively, whereas male A, male C and female B had a pelvic anterior tilting of 3 degrees, 9 degrees and 4 degrees respectively. In addition, the 6 patients the values of lumbar lordosis angle, lumbosacral angle and sacral slope that were almost twice as much as the normal standard values of Koreans. It is believed that this is because the pelvic sacral slope maintaining an angle that is slightly greater than the normal range by being located in the lowest end of spine considering that the compensation for pelvic tilt, in other words, pelvic limb is not much causes an excess of lumbar lordosis angle. The meaning of this study based on these results is to prove that PSA is one of the important factors that fundamentally determine lumbar curvature. And this is because it is definitely required to have a study on the guideline for appropriate posture and life habit to the maintenance and management of ideal PSA before the end of growth phase and also the exercise therapy and adjustment for the control of PSA.

Sacral Nerve Stimulation For Urinary Urge Incontinence, Urgency-Frequency, Urinary Retention, and Fecal Incontinence

PubMed Central

2005-01-01

Executive Summary Objective The aim of this review was to assess the effectiveness, safety, and cost of sacral nerve stimulation (SNS) to treat urinary urge incontinence, urgency-frequency, urinary retention, and fecal incontinence. Background: Condition and Target Population Urinary urge incontinence, urgency-frequency, urinary retention, and fecal incontinence are prevalent, yet rarely discussed, conditions. They are rarely discussed because patients may be uncomfortable disclosing their symptoms to a health professional or may be unaware that there are treatment options for these conditions. Briefly, urge incontinence is an involuntary loss of urine upon a sudden urge. Urgency-frequency is an uncontrollable urge to void, which results in frequent, small-volume voids. People with urgency-frequency may or may not also experience chronic pelvic pain. Urinary retention refers to the inability to void despite having the urge to void. It can be caused by a hypocontractile detrusor (weak or no bladder muscle contraction) or obstruction due to urethral overactivity. Fecal incontinence is a loss of voluntary bowel control. The prevalence of urge incontinence, urgency-frequency, and urinary retention in the general population is 3.3% to 8.2%, and the prevalence of fecal incontinence is 1.4% to 1.9%. About three-quarters of these people will be successfully treated by behaviour and/or drug therapy. For those who do not respond to these therapies, the options for treatment are management with diapers or pads, or surgery. The surgical procedures are generally quite invasive, permanent, and are associated with complications. Pads and/or diapers are used throughout the course of treatment as different therapies are tried. Patients who respond successfully to treatment may still require pads or diapers, but to a lesser extent. The Technology Being Reviewed: Sacral Nerve Stimulation Sacral nerve stimulation is a procedure where a small device attached to an electrode is implanted in the abdomen or buttock to stimulate the sacral nerves in an attempt to manage urinary urge incontinence, urgency-frequency, urinary retention, and fecal incontinence. The device was originally developed to manage urinary urge incontinence; however, it has also been used in patients with urgency-frequency, urinary retention, and fecal incontinence. SNS is intended for patients who are refractory to behaviour, drug, and/or interventional therapy. There are 2 phases in the SNS process: first, patients must undergo a test stimulation phase to determine if they respond to sacral nerve stimulation. If there is a 50% or greater improvement in voiding function, then the patient is considered a candidate for the next phase, implantation. Review Strategy The standard Medical Advisory Secretariat search strategy was used to locate international health technology assessments and English-language journal articles published from 2000 to November 2004. The Medical Advisory Secretariat also conducted Internet searches of Medscape (1) and the manufacturer’s website (2) to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. In addition, the Web site Current Controlled Trials (3) was searched for ongoing randomized controlled trials (RCTs) investigating the role of sacral nerve stimulation in the management of voiding conditions. Summary of Findings Four health technology assessments were found that reviewed SNS in patients with urge incontinence, urgency-frequency, and/or urinary retention. One assessment was found that reviewed SNS in patients with fecal incontinence. The assessments consistently reported that SNS was an effective technology in managing these voiding conditions in patients who did not respond to drug or behaviour therapy. They also reported that there was a substantial complication profile associated with SNS. Complication rates ranged from 33% to 50%. However, none of the assessments reported that they found any incidences of permanent injury or death associated with the device. The health technology assessments for urge incontinence, urgency-frequency, and urinary retention included (RCTs (level 2) as their primary source of evidence for their conclusions. The assessment of fecal incontinence based its conclusions on evidence from case series (level 4). Because there was level 2 data available for the use of SNS in patients with urinary conditions, the Medical Advisory Secretariat chose to review thoroughly the RCTs included in the assessments and search for publications since the assessments were released. However, for the health technology assessment for fecal incontinence, which contained only level 4 evidence, the Medical Advisory Secretariat searched for studies on SNS and fecal incontinence that were published since that assessment was released. Urge Incontinence Two RCTs were identified that compared SNS to no treatment in patients with refractory urge incontinence. Both RCTs reported significant improvements (> 50% improvement in voiding function) in the SNS group for number of incontinence episodes per day, number of pads used per day, and severity of incontinence episodes. Urgency-Frequency (With or Without Chronic Pelvic Pain) One RCT was identified that compared SNS to no treatment in patients with refractory urgency-frequency. The RCT reported significant improvements in urgency-frequency symptoms in the SNS group (average volume per void, detrusor pressure). In addition to the RCT, 1 retrospective review and 2 prospective case series were identified that measured pelvic pain associated with urgency-frequency in patients who underwent SNS. All 3 studies reported a significant decrease in pain at median follow-up. Urinary Retention One RCT was identified that compared SNS to no treatment in patients with refractory urinary retention. The RCT reported significant improvements in urinary retention in the SNS group compared to the control group for number of catheterizations required and number of voids per day. In addition to this RCT, 1 case series was also identified investigating SNS in women with urinary retention. This study also found that there were significant improvements in urinary retention after the women had received the SNS implants. Fecal Incontinence Three case series were identified that investigated the role of SNS in patients with fecal incontinence. All 3 reported significant improvements in fecal incontinence symptoms (number of incontinent episodes per week) after the patients received the SNS implants. Long-Term Follow-up None of the studies identified followed patients until the point of battery failure. Of the 6 studies identified describing the long-term follow-up of patients with SNS, follow-up periods ranged from 1.5 years to over 5 years. None of the long-term follow-up studies included patients with fecal incontinence. All of the studies reported that most of the patients who had SNS had at least a 50% improvement in voiding function (range 58%–77%). These studies also reported the number of patients who had their device explanted in the follow-up period. The rates of explantation ranged from 12% to 21%. Safety, Complications, and Quality of Life A 33% surgical revision rate was reported in an analysis of the safety of 3 RCTs comparing SNS to no treatment in patients with urge incontinence, urgency-frequency, or urinary retention. The most commonly reported adverse effects were pain at the implant site and lead migration. Despite the high rate of surgical revision, there were no reports of permanent injury or death in any of the studies or health technology assessments identified. Additionally, patients consistently said that they would recommend the procedure to a friend or family member. Economic Analysis One health technology assessment and 1 abstract were found that investigated the costing factors pertinent to SNS. The authors of this assessment did their own “indicative analysis” and found that SNS was not more cost-effective than using incontinence supplies. However, the assessment did not account for quality of life. Conversely, the authors of the abstract found that SNS was more cost-effective than incontinence supplies alone; however, they noted that in the first year after SNS, it is much more expensive than only incontinence supplies. This is owing to the cost of the procedure, and the adjustments required to make the device most effective. They also noted the positive effects that SNS had on quality of life. Conclusions and Implications In summary, there is level 2 evidence to support the effectiveness of SNS to treat people with urge incontinence, urgency-frequency, or urinary retention. There is level 4 evidence to support the effectiveness of SNS to treat people with fecal incontinence. To qualify for SNS, people must meet the following criteria: Be refractory to behaviour and/or drug therapy Have had a successful test stimulation before implantation; successful test stimulation is defined by a 50% or greater improvement in voiding function based on the results of a voiding diary. Test stimulation periods range from 3 to 7 days for patients with urinary dysfunctions, and from 2 to 3 weeks for patients with fecal incontinence. Be able to record voiding diary data, so that clinical results of the implantation can be evaluated. Patients with stress incontinence, urinary retention due to obstruction and neurogenic conditions (such as diabetes with peripheral nerve involvement) are ineligible for sacral nerve stimulation. Physicians will need to learn how to use the InterStim System for Urinary Control. Requirements for training include these: Physicians must be experienced in the diagnosis and treatment of lower urinary tract disorders and should be trained in the implantation and use of the InterStim System for Urinary Control. Training should include the following: Participation in a seminar or workshop that includes instructional and laboratory training on SNS. This seminar should include a review of the evidence on SNS with emphasis on techniques to prevent adverse events. Completion of proctoring by a physician experienced in SNS for the first 2 test stimulations and the first 2 implants PMID:23074472

Notes on nervios: a disorder of menopause.

PubMed

Barnett, E A

1989-01-01

The condition of nerves among women in the small Peruvian town of Puente Piedre is described. Both nervios (a symptom) and Nervios (a disorder) describe a woman's difficulty with nerves. In Puente Piedre, the identification of an anxiety condition among women depends only on the women's age. Younger women with anxiety symptoms are diagnosed as nervios, a temporary condition ascribed to a single episode of high blood pressure. Menopausal women with similar symptoms, on the other hand, are thought to have a specific disorder, Nervios. In Puente Piedre, Nervios clearly is a folk illness limited to women of menopausal age.

The presence of a negative sacral slope in patients with ankylosing spondylitis with severe thoracolumbar kyphosis.

PubMed

Qian, Bang-Ping; Jiang, Jun; Qiu, Yong; Wang, Bin; Yu, Yang; Zhu, Ze-Zhang

2014-11-19

Pelvic retroversion is one of the mechanisms for regulating sagittal balance in patients with a kyphotic deformity. This retroversion is limited by hip extension, which prevents the pelvis from becoming excessively retroverted, achieving a sacral slope of <0°. However, a negative sacral slope can be found in some patients with ankylosing spondylitis with thoracolumbar kyphosis. The purpose of this study was to analyze this finding. We performed a retrospective review of 106 consecutive Chinese Han patients with ankylosing spondylitis with thoracolumbar kyphosis treated at our center from October 2005 to October 2012. Forty-one patients in whom the upper third of the femur was clearly visualized on lateral radiographs were analyzed. Seventeen had a sacral slope of <0° (group A) and twenty-four had a sacral slope of ≥0° (group B). Eight sagittal parameters were measured and compared between the two groups. Correlations among sacral slope, the femoral obliquity angle, and the other sagittal parameters were analyzed. Mean global kyphosis, lumbar lordosis, pelvic tilt, the sagittal vertical axis, and the femoral obliquity angle were significantly larger in group A than in group B, whereas mean pelvic incidence and sacral slope were significantly smaller in group A (p < 0.05 for all). Global kyphosis, lumbar lordosis, pelvic tilt, and the sagittal vertical axis were significantly negatively associated with sacral slope but positively associated with the femoral obliquity angle, whereas pelvic incidence was significantly positively associated with sacral slope but negatively associated with the femoral obliquity angle (p < 0.05 for all). The femoral obliquity angle was significantly negatively associated with sacral slope (p < 0.05). Negative sacral slope does exist in Chinese Han patients with ankylosing spondylitis with thoracolumbar kyphosis. This appears to be caused by severe kyphosis, an initially small sacral slope, and pronounced tilting of the femoral shaft as a result of knee flexion, resulting in the pelvis becoming further retroverted. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

Combined maceration procedure permits advanced microsurgical dissection of Thiel-embalmed specimens.

PubMed

Bangerter, Hannes; Boemke, Susanne; Röthlisberger, Raphael; Schwartz, Valerie; Bergmann, Mathias; Müller, Michael D; Djonov, Valentin

2017-03-01

Due to the realistic colour, texture conservation and preservation of biomechanical properties, Thiel-embalming is becoming the main embalming procedure for clinical courses and research based on human cadaver material. The aim of this study is to establish a new procedure that allows advanced microdissection of small vessels and intraorganic nerves in Thiel-embalmed material. After a classical gross anatomical dissection, human hemipelves underwent repetitive application of 3 consecutive steps: (i) maceration with alloy of nitric acid and MiliQ water 1:10 for 24-48h. (ii) Immersion: the hemipelves were rinsed under tap water for 20-30min. and placed in a water bath for 1h. The nerves become more prominent due to the swelling and increased water content. (iii) microdissection under surgical microscope. To facilitate the organ visualization perfusion with polyurethane (Pu4ii, VasQtec ® , Switzerland) in red/blue for arteries/veins respectively has been performed. By using the proposed procedure, we performed satisfactory microdissection on Thiel-embalmed samples. The combination with polyurethane vascular casting permits visualization of small arterioles and venules in a range of 20-25μm. The method is very suitable for demonstration of somatic and vegetative nerves. Branches of the sacral plexuses and autonomic nerves from the superior and inferior hypogastric plexus have been tracked up to the smallest intraorganic branches in a range of 12.5-15μm. In conclusion, the established combined procedure offers a new possibility for advanced microdissection, which will allow acquisition of clinically relevant information about organ specific micro- vascularization and innervation. Copyright © 2016 Elsevier GmbH. All rights reserved.

Sacral Peak Pressure in Healthy Volunteers and Patients With Spinal Cord Injury: With and Without Liquid-Based Pad.

PubMed

Duetzmann, Stephan; Forsey, Lynn M; Senft, Christian; Seifert, Volker; Ratliff, John; Park, Jon

2015-01-01

The prevalence of sacral pressure ulcers in patients with spinal cord injuries is high. The sacral area is vulnerable to compressive pressure because of immobility and because the sacrum and posterior superior iliac prominence lie closely under the skin with no muscle layer in between. The aim of this study was to assess peak sacral pressure before and after use of PURAP, a liquid-based pad that covers only the sacral area and can be applied on any bed surface. Healthy volunteers (n = 12) and patients with spinal cord injuries (n = 10) took part; the patients had undergone spine surgery within 7 days before data collection. Participants were in bed, pretest pressure maps were generated, PURAP was placed for 15 minutes, and then posttest pressure maps were generated. Peak pressure was obtained every second and averaged over the entire period. Patients rated whether their comfort had improved when PURAP was in use. For healthy volunteers, mean pretest peak sacral pressure was 74.7 (SD = 16.2) mmHg; the posttest mean was 49.1 (SD = 7.5) mmHg (p < .001, Wilcoxon signed-rank test). For patients with spinal cord injuries, mean pretest peak sacral pressure was 105.7 (SD = 22.4) mmHg; the posttest mean was 81.4 (SD = 18.3) mmHg (p < .001, Wilcoxon signed-rank test). The pad reduced the peak sacral pressure in the patient group by 23% (range = 11%-42%) and in the volunteers by 32% (range = 19%-46%). Overall, 70% of the patients reported increased comfort with PURAP. Peak sacral pressure was reduced when PURAP was used. It covers only the sacral area but could help many patients with spinal cord injury because the prevalence of sacral pressure ulcers is high in this group. PURAP may be economically advantageous in countries and hospitals with limited financial resources needed for more expensive mattresses and cushions.

Gamma Knife® radiosurgery for trigeminal neuralgia.

PubMed

Yen, Chun-Po; Schlesinger, David; Sheehan, Jason P

2011-11-01

Trigeminal neuralgia is characterized by a temporary paroxysmal lancinating facial pain in the trigeminal nerve distribution. The prevalence is four to five per 100,000. Local pressure on nerve fibers from vascular loops results in painful afferent discharge from an injured segment of the fifth cranial nerve. Microvascular decompression addresses the underlying pathophysiology of the disease, making this treatment the gold standard for medically refractory trigeminal neuralgia. In patients who cannot tolerate a surgical procedure, those in whom a vascular etiology cannot be identified, or those unwilling to undergo an open surgery, stereotactic radiosurgery is an appropriate alternative. The majority of patients with typical facial pain will achieve relief following radiosurgical treatment. Long-term follow-up for recurrence as well as for radiation-induced complications is required in all patients undergoing stereotactic radiosurgery for trigeminal neuralgia.

[Selective neck dissection for treating recurrent branchial anomalies].

PubMed

Chen, Liangsi; Song, Xinhan; Zhang, Siyi; Han, Zhijuan; Luo, Xiaoning; Chen, Shaohua; Zhan, Jiandong

2011-01-01

To evaluate the role of selective neck dissection in the treatment of recurrent branchial anomalies. The clinical data of 18 patients with recurrent branchial anomalies were retrospectively analyzed. In accordance with the embryologic and anatomic features of branchial anomalies, different types of selective neck dissection were applied. With dissection and protection of important vessels, nerves and other structures, enbloc resection principles were applied to extirpate branchial lesions, scarrings and inflammatory granuloma during the operation. Of all 18 patients, 16 cases were healed with primary healing, 2 cases with local incision infection were healed after dressing changes. A temporary facial nerve paralysis occurred in 1 case with recurrent first branchial cleft fistula postoperatively, and completely recovered 2 months after operation. A postoperative temporary vocal cord paralysis occurred in 1 case with recurrent fourth branchial cleft fistula, and totally recuperated 1 month after operation. No recurrences were found in all 18 cases with a follow-up period of 12-78 months (average 35 months). Selective neck dissection is a safe and effective surgical procedure for the radical treatment of recurrent branchial anomalies.

Landmarks for Sacral Debridement in Sacral Pressure Sores.

PubMed

Choo, Joshua H; Wilhelmi, Bradon J

2016-03-01

Most cases of sacral osteomyelitis arising in the setting of sacral pressure ulcers require minimal cortical debridement. When faced with advanced bony involvement, the surgeon is often unclear about how much can safely be resected. Unfamiliarity with sacral anatomy can lead to concerns of inadvertent entry into the dural space and compromise of future flap options. A cadaveric study (n = 6), in which a wide posterior dissection of the sacrum, was performed. Relationships of the dural sac to bony landmarks of the posterior pelvis were noted. The termination of the dural sac was found in our study to occur at the junction of S2/S3 vertebral bodies, which was located at a mean distance of 0.38 ± 0.16 cm distal to the inferior-most extent of the posterior superior iliac spine (PSIS). The mean thickness of the posterior table of sacrum at this level was 1.7 cm at the midline and 0.5 cm at the sacral foramina. The PSIS is a reliable landmark for localizing the S2/S3 junction and the termination of the dural sac. Sacral debridement medial to the sacral foramina above the level of PSIS must be conservative whenever possible. If aggressive debridement is necessary above this level, the surgeon must be alert to the possibility of dural involvement.

Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15mm approach: Feasibility study.

PubMed

Zemirline, A; Taleb, C; Naito, K; Vernet, P; Liverneaux, P; Lebailly, F

2018-05-17

Distal radius fractures (DRF) may trigger, reveal or decompensate acute carpal tunnel syndrome (CTS) in 0.5-21% of cases. Internal fixation and median nerve release must then be carried out urgently. Less invasive approaches have been described for both the median nerve release using an endoscopic device and for the DRF fixation using a volar locking plate. We assessed the feasibility of DRF fixation and median nerve release through a single, minimally-invasive 15mm approach on a series of 10 cases. We reviewed retrospectively 10 consecutive cases of DRF associated with symptomatic CTS in 8 women and 2 men, aged 57 years on average. CTS was diagnosed clinically. All patients were treated during outpatient surgery with a volar locking plate and endoscopic carpal tunnel release using a single 15mm minimally-invasive approach. In one case, arthroscopic scapholunate repair was also required. Six months after the procedure, all patients were reviewed with a clinical examination and a radiological evaluation. The average values for the clinical and radiological outcomes were as follows: pain on VAS 1.5/10; QuickDASH 14.3/100; flexion 90%; extension 90.6%; pronation 95.6%; supination 87.9%; grip strength 90.1%; 2PD test 5.2mm (4-8mm). Five complications occurred: two cases of temporary dysesthesia in the territory of the median nerve and one case of temporary hypoesthesia of the palmar branch of the median nerve, which had all completely recovered; two cases of complex regional pain syndrome type I, which were still active at 6 months. Despite its methodological weaknesses, our study is the only one to describe the technical feasibility of a single 15mm minimally-invasive approach for both internal fixation using a volar locking plate and endoscopic nerve release, with no serious complications. This technique should be added to the surgical toolbox of minimally-invasive procedures for the hand and wrist. Copyright © 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.

Prophylactic Sacral Dressing for Pressure Ulcer Prevention in High-Risk Patients.

PubMed

Byrne, Jaime; Nichols, Patricia; Sroczynski, Marzena; Stelmaski, Laurie; Stetzer, Molly; Line, Cynthia; Carlin, Kristen

2016-05-01

Patients in intensive care units are likely to have limited mobility owing to hemodynamic instability and activity orders for bed rest. Bed rest is indicated because of the severity of the disease process, which often involves intubation, sedation, paralysis, surgical procedures, poor nutrition, low flow states, and poor circulation. These patients are predisposed to the development and/or the progression of pressure ulcers not only because of their underlying diseases, but also because of limited mobility and deconditioned states of health. To assess whether treating high-risk patients with a prophylactic sacral dressing decreases the incidence of unit-acquired sacral pressure ulcers. An evidence-based tool for identifying patients at high risk for pressure ulcers was used in 3 intensive care units at an urban tertiary care hospital and academic medical center. Those patients deemed at high risk had a prophylactic sacral dressing applied. Incidence rates were collected and compared for the 7 months preceding use of the dressings and for 7 months during the trial period when the dressing was used. After the sacral dressing began being used, the number of unit-acquired sacral pressure ulcers decreased by 3.4 to 7.6 per 1000 patient days depending on the unit. A prophylactic sacral dressing may help prevent unit-acquired sacral pressure ulcers. Implementation of an involved care team with heightened awareness and increased education along with a prophylactic sacral dressing in patients deemed high risk for skin breakdown are all essential for success. ©2016 American Association of Critical-Care Nurses.

Sacral Variability in Tailless Species: Homo sapiens and Ochotona princeps.

PubMed

Tague, Robert G

2017-05-01

Homo sapiens is variable in number of sacral vertebrae, and this variability can lead to obstetrical complication. This study uses the comparative method to test the hypothesis that sacral variability in H. sapiens is associated with absence of a tail. Three species of lagomorphs are studied: Ochotona princeps (N = 271), which is tailless, and Lepus californicus (N = 212) and Sylvilagus audubonii (N = 206), which have tails. Results show that O. princeps has (1) higher diversity index for number of sacral vertebrae (0.49) compared to L. californicus (0.25) and S. audubonii (0.26) and (2) significantly higher percentage of individuals with the species-specific nonmodal number of sacral vertebrae (43.9%) compared to L. californicus (14.2%) and S. audubonii (15.5%). Comparison of H. sapiens (N = 1,030; individuals of age 20-39 years) with O. princeps shows similarities between the species in diversity index (also 0.49 in H. sapiens) and percentage of individuals with nonmodal number of sacral vertebrae (37.3% in H. sapiens). Homeotic transformation best explains the results. H. sapiens and O. princeps show propensity for caudal shift at the sacral-caudal border (i.e., homeotic transformation of the first caudal vertebra to a sacral vertebra). Caudal and cranial shift among presacral vertebrae increases or decreases this propensity, respectively. Increase in number of sacral vertebrae in H. sapiens by homeotic transformation reduces pelvic outlet capacity and can be obstetrically hazardous. Anat Rec, 300:798-809, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Critical dimensions of trans-sacral corridors assessed by 3D CT models: Relevance for implant positioning in fractures of the sacrum.

PubMed

Wagner, Daniel; Kamer, Lukas; Sawaguchi, Takeshi; Geoff Richards, R; Noser, Hansrudi; Uesugi, Masafumi; Ossendorf, Christian; Rommens, Pol M

2017-11-01

Trans-sacral implants can be used alternatively to sacro-iliac screws in the treatment of osteoporosis-associated fragility fractures of the pelvis and the sacrum. We investigated trans-sacral corridor dimensions, the number of individuals amenable to trans-sacral fixation, as well as the osseous boundaries and shape of the S1 corridor. 3D models were reconstructed from pelvic CT scans from 92 Europeans and 64 Japanese. A corridor of <12 mm was considered critical for trans-sacral implant positioning, and <8 mm as impossible. A statistical model of trans-sacral corridor S1 was computed. The limiting cranio-caudal diameter was 11.6 mm (±5.4) for S1 and 14 mm (±2.4) for S2. Trans-sacral implant positioning was critical in 52% of cases for S1, and in 21% for S2. The S1 corridor was impossible in 26%, with no impossible corridor in S2. Antero-superiorly, the S1 corridor was limited not only by the sacrum but in 40% by the iliac fossa. The statistical model demonstrated a consistent oval shape of the trans-section of corridor S1. Considering the variable in size and shape of trans-sacral corridors in S1, a thorough anatomical knowledge and preoperative planning are mandatory using trans-sacral implants. In critical cases, S2 is a veritable alternative. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2577-2584, 2017. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Malignant fibrous histiocytoma developing in irradiated sacral chordoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Halpern, J.; Kopolovic, J.; Catane, R.

1984-06-15

Malignant fibrous histiocytoma (MFH), arising at the site of a sacral chordoma 8 years after massive radiotherapy, is described. Initially, the patient received 7000 rad to the sacral area and, on recurrence, 5 years later, an additional 4000 rad. Two years later, a sacral mass was noted again. Biopsy then revealed MFH; chest x-ray showed multiple lung metastases. A combination chemotherapy, consisting of cyclophosphamide, vincristine, adriamycin (doxorubicin), and DTIC, resulted in a 6 month partial response. Subsequently, the patient died because of progressive metastatic disease. At autopsy, 8 years after diagnosis, both the sacral lesion and the lung metastases provedmore » to be MFH, and no residual chordoma was found.« less

The predictive value of the sacral base pressure test in detecting specific types of sacroiliac dysfunction

PubMed Central

Mitchell, Travis D.; Urli, Kristina E.; Breitenbach, Jacques; Yelverton, Chris

2007-01-01

Abstract Objective This study aimed to evaluate the validity of the sacral base pressure test in diagnosing sacroiliac joint dysfunction. It also determined the predictive powers of the test in determining which type of sacroiliac joint dysfunction was present. Methods This was a double-blind experimental study with 62 participants. The results from the sacral base pressure test were compared against a cluster of previously validated tests of sacroiliac joint dysfunction to determine its validity and predictive powers. The external rotation of the feet, occurring during the sacral base pressure test, was measured using a digital inclinometer. Results There was no statistically significant difference in the results of the sacral base pressure test between the types of sacroiliac joint dysfunction. In terms of the results of validity, the sacral base pressure test was useful in identifying positive values of sacroiliac joint dysfunction. It was fairly helpful in correctly diagnosing patients with negative test results; however, it had only a “slight” agreement with the diagnosis for κ interpretation. Conclusions In this study, the sacral base pressure test was not a valid test for determining the presence of sacroiliac joint dysfunction or the type of dysfunction present. Further research comparing the agreement of the sacral base pressure test or other sacroiliac joint dysfunction tests with a criterion standard of diagnosis is necessary. PMID:19674694

Herpes zoster in African patients: an early manifestation of HIV infection.

PubMed

Van de Perre, P; Bakkers, E; Batungwanayo, J; Kestelyn, P; Lepage, P; Nzaramba, D; Bogaerts, J; Serufilira, A; Rouvroy, D; Uwimana, A

1988-01-01

During a 3-month period, 131 cases of herpes zoster were diagnosed in Kigali, Rwanda. There were 46 female and 85 male patients. Mean age was 29 years (range 1-66). An unusually high proportion of patients presented with cranial and sacral nerve localisation of their cutaneous lesions. 55/131 patients (42%) had involvement of more than one dermatome. None of the patients had an underlying condition known to favour herpes zoster. 120/131 (92%) had antibodies to HIV detected by an immunoenzymatic assay (EIA) and indirect immunofluorescence. 92/125 adult patients (74%) had no sign or symptom related to HIV infection other than herpes zoster. This study suggests that herpes zoster in Central Africa is an early and readily detectable manifestation of HIV-induced immunosuppression.

Restoration of bladder function in spastic neuropathic bladder using sacral deafferentation and different techniques of neurostimulation.

PubMed

Schumacher, S; Bross, S; Scheepe, J R; Alken, P; Jünemann, K P

1999-01-01

Conventional sacral anterior root stimulation (SARS) results in simultaneous activation of both the detrusor muscle and the external urethral sphincter. We evaluated the possibilities of different neurostimulation techniques to overcome stimulation induced detrusor-sphincter-dyssynergia and to achieve a physiological voiding. The literature was reviewed on different techniques of sacral anterior root stimulation of the bladder and the significance of posterior rhizotomy in patients with supraconal spinal cord injury suffering from the loss of voluntary bladder control, detrusor hyperreflexia and sphincter spasm. The achievement of selective detrusor activation would improve current sacral neurostimulation of the bladder, including the principle of "poststimulus voiding". This is possible with the application of selective neurostimulation in techniques of anodal block, high frequency block, depolarizing prepulses and cold block. Nowadays, sacral deafferentation is a standard therapy in combination with neurostimulation of the bladder because in conclusion advantages of complete rhizotomy predominate. The combination of sacral anterior root stimulation and sacral deafferentation is a successful procedure for restoration of bladder function in patients with supraconal spinal cord injury. Anodal block technique and cryotechnique are excellent methods for selective bladder activation to avoid detrusor-sphincter-dyssynergia and thus improve stimulation induced voiding.

Paraspinal Transposition Flap for Reconstruction of Sacral Soft Tissue Defects: A Series of 53 Cases from a Single Institute

PubMed Central

Chattopadhyay, Debarati; Agarwal, Akhilesh Kumar; Guha, Goutam; Bhattacharya, Nirjhar; Chumbale, Pawan K; Gupta, Souradip; Murmu, Marang Buru

2014-01-01

Study Design Case series. Purpose To describe paraspinal transposition flap for coverage of sacral soft tissue defects. Overview of Literature Soft tissue defects in the sacral region pose a major challenge to the reconstructive surgeon. Goals of sacral wound reconstruction are to provide a durable skin and soft tissue cover adequate for even large sacral defects; minimize recurrence; and minimize donor site morbidity. Various musculocutaneous and fasciocutanous flaps have been described in the literature. Methods The flap was applied in 53 patients with sacral soft tissue defects of diverse etiology. Defects ranged in size from small (6 cm×5 cm) to extensive (21 cm×10 cm). The median age of the patients was 58 years (range, 16-78 years). Results There was no flap necrosis. Primary closure of donor sites was possible in all the cases. The median follow up of the patients was 33 months (range, 4-84 months). The aesthetic outcomes were acceptable. There has been no recurrence of pressure sores. Conclusions The authors conclude that paraspinal transposition flap is suitable for reconstruction of large sacral soft tissue defects with minimum morbidity and excellent long term results. PMID:24967044

Hemilingual spasm: defining a new entity, its electrophysiological correlates and surgical treatment through microvascular decompression.

PubMed

Osburn, Leisha L; Møller, Aage R; Bhatt, Jay R; Cohen-Gadol, Aaron A

2010-07-01

We report on vascular compression syndrome of the 12th cranial nerve (hypoglossal), an occurrence not previously reported, and demonstrate, through corresponding objective electrophysiological evidence, that microvascular decompression of the hypoglossal nerve root can cure hemilingual spasm. A 52-year-old man had lower face muscle twitching and tongue spasms, which worsened with talking, chewing, or emotional stress. Carbamazepine offered only temporary relief, and relief from injections of botulinum toxin was insignificant. He was referred for surgical treatment. High-resolution magnetic resonance imaging of his posterior fossa contents revealed no obvious evidence of any compressive vessel along the facial nerve, but a compressive vessel along the hypoglossal nerve was apparent. The presence of preoperative tongue spasms encouraged interoperative monitoring of tongue motor responses. The facial nerve exit zone was explored, but microsurgical inspection of the seventh/eighth cranial nerve complex did not reveal any compressive vessel. However, at the anterolateral aspect of the medulla oblongata, the hypoglossal nerve was clearly compressed and distorted laterally by a large tortuous vertebral artery. When the artery was mobilized away from the nerve, the abnormal late electromyographic response to transcranial electrical stimulation disappeared; immediately after shredded Teflon was interpositioned between the artery and the nerve, the abnormal spontaneous tongue fasciculation also disappeared. The patient has remained spasm free 6 months after surgery. Hemilingual spasm may be caused by vascular contact/compression along cranial nerve XII at the lower brainstem and belong to the same family of cranial nerve hyperactivity disorders as hemifacial spasm.

Phrenic nerve stimulation during neck dissection for advanced thyroid cancer involving level IV: is it worth doing it?

PubMed

Duque, Carlos S; Dueñas, Juan P; Marulanda, Marcela; Pérez, Diana; Londoňo, Andres; Roy, Soham; Khadem, Mai Al

2017-03-01

During thyroidectomy and neck dissection surgery for advanced or recurrent metastatic thyroid cancer under intraoperative monitoring, we used the available technology to assess the feasibility of such an intervention to monitor those patients with phrenic nerves at risk. A retrospective review of patients operated on from January 2009 to December 2015 by a single surgeon (CSD) was conducted. Patients who had neck and mediastinal dissection, with or without total thyroidectomy, due to advanced or recurrent metastatic disease to the neck were selected. The procedures were done under intraoperative nerve monitoring using nerve monitoring systems (NIM 2.0 or 3.0; Medtronic, Jacksonville, FL, USA). A total of 19 patients were included in the study, with a mean age of 57.6 years ± 16.3 and a male/female ratio of 10:9. Overall, all patients had an intact phrenic nerve at the conclusion of the surgery. One patient had an aggressive tumor that precluded sacrifice of the left recurrent laryngeal nerve and ipsilateral thoracic duct. The procedure was complicated by a temporary impairment of the diaphragm contraction with intraoperative nerve monitoring as well as a chyle fistula. This was due to the manipulation of the tissue surrounding the phrenic nerve. Intraoperative nerve monitoring of the phrenic nerve offers the surgeon a "potential" method of ensuring phrenic nerve integrity in cases of advanced thyroid cancers with gross level IV metastatic disease. Further prospective studies are needed to assess the risks of this intervention and evaluate the method of recording diaphragm contraction movement.

Developmental identity versus typology: Lucy has only four sacral segments.

PubMed

Machnicki, Allison L; Lovejoy, C Owen; Reno, Philip L

2016-08-01

Both interspecific and intraspecific variation in vertebral counts reflect the action of patterning control mechanisms such as Hox. The preserved A.L. 288-1 ("Lucy") sacrum contains five fused elements. However, the transverse processes of the most caudal element do not contact those of the segment immediately craniad to it, leaving incomplete sacral foramina on both sides. This conforms to the traditional definition of four-segmented sacra, which are very rare in humans and African apes. It was recently suggested that fossilization damage precludes interpretation of this specimen and that additional sacral-like features of its last segment (e.g., the extent of the sacral hiatus) suggest a general Australopithecus pattern of five sacral vertebrae. We provide updated descriptions of the original Lucy sacrum. We evaluate sacral/coccygeal variation in a large sample of extant hominoids and place it within the context of developmental variation in the mammalian vertebral column. We report that fossilization damage did not shorten the transverse processes of the fifth segment of Lucy's sacrum. In addition, we find that the extent of the sacral hiatus is too variable in apes and hominids to provide meaningful information on segment identity. Most importantly, a combination of sacral and coccygeal features is to be expected in vertebrae at regional boundaries. The sacral/caudal boundary appears to be displaced cranially in early hominids relative to extant African apes and humans, a condition consistent with the likely ancestral condition for Miocene hominoids. While not definitive in itself, a four-segmented sacrum accords well with the "long-back" model for the Pan/Homo last common ancestor. Am J Phys Anthropol 160:729-739, 2016. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

The neurophysiology of urinary retention in young women and its treatment by neuromodulation.

PubMed

Goodwin, R J; Swinn, M J; Fowler, C J

1998-01-01

Urinary retention occurring in young women as an isolated phenomenon was often thought to be psychogenic in origin. However, in 1988, Fowler et al. described a syndrome in young women in which urinary retention was the predominant feature and in which electromyography (EMG) of the striated urethral sphincter revealed a striking abnormality. This abnormality, it was postulated, would result in an inability of the sphincter to relax and retention would therefore result. Until recently there was no effective treatment for this disorder except management by clean intermittent self-catheterisation. However, preliminary results of neuromodulation using a Medtronic sacral nerve stimulator have been particularly promising in this group of patients. The response is often spectacular; a woman who has not passed urine per urethram for many months or years will frequently find that within a few hours of insertion of the percutaneous nerve evaluation (PNE) lead, she can void quite normally with little or no residual urine. The precise mechanism of action is yet to be defined, but measurements of the latency of anal sphincter contraction on S3 stimulation during PNE are so prolonged that they can only be the result of an afferent-mediated reflex.

Nonantimuscarinic treatment for overactive bladder: a systematic review.

PubMed

Olivera, Cedric K; Meriwether, Kate; El-Nashar, Sherif; Grimes, Cara L; Chen, Chi Chiung Grace; Orejuela, Francisco; Antosh, Danielle; Gleason, Jon; Kim-Fine, Shunaha; Wheeler, Thomas; McFadden, Brook; Balk, Ethan M; Murphy, Miles

2016-07-01

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder. Copyright © 2016 Elsevier Inc. All rights reserved.

Interpedicular Approach in Percutaneous Sacroplasty for Treatment of Sacral Vertebral Body Pathologic Fractures

DOE Office of Scientific and Technical Information (OSTI.GOV)

F Latin-Small-Letter-Dotless-I rat, Ahmet Kemal, E-mail: ahmetfirat2@hotmail.com; Guemues, Burcak, E-mail: bgumus@yahoo.com; Kaya, Emin, E-mail: ekaya@inonu.edu.tr

2011-02-15

For this technique, bone needle is introduced into the S1 vertebral body through the interpedicular route by penetrating the central spinal canal at the level of S3-4 and passing through the vertebral body of S2-3 parallel to the anterior border of sacrum. With the interpedicular approach, two sacral vertebral bodies can be injected in one session and lower sacral body injection also is available. interpedicular technique is a safe, practical, and effective technique for the treatment of sacral vertebral body pathologic fractures.

Sacral Stress Fracture Mimicking Lumbar Radiculopathy in a Mounted Police Officer: Case Report and Literature Review.

PubMed

Bednar, Drew A; Almansoori, Khaled

2015-10-01

Study Design Case report and review of the literature. Objective To present a unique case of L5 radiculopathy caused by a sacral stress fracture without neurologic compression. Methods We present our case and its clinical evolution and review the available literature on similar pathologies. Results Relief of the unusual mechanical loading causing sacral stress fracture led to rapid resolution of radiculopathy. Conclusion L5 radiculopathy can be caused by a sacral stress fracture and can be relieved by simple mechanical treatment of the fracture.

Neuroanatomic and behavioral correlates of urinary dysfunction induced by vaginal distension in rats.

PubMed

Palacios, J L; Juárez, M; Morán, C; Xelhuantzi, N; Damaser, M S; Cruz, Y

2016-05-01

The aim of the present study was to use a model of simulated human childbirth in rats to determine the damage to genitourinary structures and behavioral signs of urinary dysfunction induced by vaginal distension (VD) in female rats. In experiment 1, the length of the genitourinary tract and the nerves associated with it were measured immediately after simulated human delivery induced by VD or sham (SH) procedures. Electroneurograms of the dorsal nerve of the clitoris (DNC) were also recorded. In experiment 2, histological characteristics of the bladder and major pelvic ganglion of VD and SH rats were evaluated. In experiment 3, urinary parameters were determined in conscious animals during 6 h of dark and 6 h of light before and 3 days after VD or SH procedures. VD significantly increased distal vagina width (P < 0.001) and the length of the motor branch of the sacral plexus (P < 0.05), DNC (P < 0.05), and vesical nerves (P < 0.01) and decreased DNC frequency and amplitude of firing. VD occluded the pelvic urethra, inducing urinary retention, hematomas in the bladder, and thinness of the epithelial (P < 0.05) and detrusor (P < 0.01) layers of the bladder. Major pelvic ganglion parameters were not modified after VD. Rats dripped urine in unusual places to void, without the stereotyped behavior of micturition after VD. The neuroanatomic injuries after VD occur alongside behavioral signs of urinary incontinence as determined by a new behavioral tool for assessing micturition in conscious animals.

Axotomy of tributaries of the pelvic and pudendal nerves induces changes in the neurochemistry of mouse dorsal root ganglion neurons and the spinal cord.

PubMed

McCarthy, Carly J; Tomasella, Eugenia; Malet, Mariana; Seroogy, Kim B; Hökfelt, Tomas; Villar, Marcelo J; Gebhart, G F; Brumovsky, Pablo R

2016-05-01

Using immunohistochemical techniques, we characterized changes in the expression of several neurochemical markers in lumbar 4-sacral 2 (L4-S2) dorsal root ganglion (DRG) neuron profiles (NPs) and the spinal cord of BALB/c mice after axotomy of the L6 and S1 spinal nerves, major tributaries of the pelvic (targeting pelvic visceral organs) and pudendal (targeting perineum and genitalia) nerves. Sham animals were included. Expression of cyclic AMP-dependent transcription factor 3 (ATF3), calcitonin gene-related peptide (CGRP), transient receptor potential cation channel subfamily V, member 1 (TRPV1), tyrosine hydroxylase (TH) and vesicular glutamate transporters (VGLUT) types 1 and -2 was analysed seven days after injury. L6-S1 axotomy induced dramatic de novo expression of ATF3 in many L6-S1 DRG NPs, and parallel significant downregulations in the percentage of CGRP-, TRPV1-, TH- and VGLUT2-immunoreactive (IR) DRG NPs, as compared to their expression in uninjured DRGs (contralateral L6-S1-AXO; sham mice); VGLUT1 expression remained unaltered. Sham L6-S1 DRGs only showed a small ipsilateral increase in ATF3-IR NPs (other markers were unchanged). L6-S1-AXO induced de novo expression of ATF3 in several lumbosacral spinal cord motoneurons and parasympathetic preganglionic neurons; in sham mice the effect was limited to a few motoneurons. Finally, a moderate decrease in CGRP- and TRPV1-like-immunoreactivities was observed in the ipsilateral superficial dorsal horn neuropil. In conclusion, injury of a mixed visceral/non-visceral nerve leads to considerable neurochemical alterations in DRGs matched, to some extent, in the spinal cord. Changes in these and potentially other nociception-related molecules could contribute to pain due to injury of nerves in the abdominopelvic cavity.

Carbon Ion Radiation Therapy for Unresectable Sacral Chordoma: An Analysis of 188 Cases

DOE Office of Scientific and Technical Information (OSTI.GOV)

Imai, Reiko, E-mail: r_imai@nirs.go.jp; Kamada, Tadashi; Araki, Nobuhito

2016-05-01

Purpose: To evaluate the results of carbon ion radiation therapy administered to 188 patients with unresectable primary sacral chordomas. Patients and Methods: One hundred eighty-eight patients were treated with carbon ion radiation therapy at a single institute between 1996 and 2013 and retrospectively analyzed. The median age was 66 years. The highest proximal invasion reached past S2 level in 137 patients. The median clinical target volume was 345 cm{sup 3}. One hundred six patients received 67.2 gray equivalents (GyE)/16 fractions (fr), 74 patients received 70.4 GyE/16 fr, 7 patients received 73.6 GyE/16 fr, and 1 patient received 64.0 GyE/16 fr. Results: The median follow-upmore » period was 62 months (range, 6.8-147.5 months). Seventy percent of patients were followed for 5 years or until death. The 5-year local control, overall survival, and disease-free survival rates were 77.2%, 81.1%, and 50.3%, respectively. Forty-one patients had a local recurrence. Sex, tumor volume, level of proximal invasion, and irradiated dose were unrelated to local control. There was grade 3 toxicity of the peripheral nerves in 6 patients and grade 4 toxicity of the skin in 2 patients. Ambulation remained in 97% of patients. Conclusions: Carbon ion radiation therapy was safe and effective for unresectable chordoma and provided good local control and survival while preserving ambulation.« less

High-resolution whole-genome analysis of skull base chordomas implicates FHIT loss in chordoma pathogenesis.

PubMed

Diaz, Roberto Jose; Guduk, Mustafa; Romagnuolo, Rocco; Smith, Christian A; Northcott, Paul; Shih, David; Berisha, Fitim; Flanagan, Adrienne; Munoz, David G; Cusimano, Michael D; Pamir, M Necmettin; Rutka, James T

2012-09-01

Chordoma is a rare tumor arising in the sacrum, clivus, or vertebrae. It is often not completely resectable and shows a high incidence of recurrence and progression with shortened patient survival and impaired quality of life. Chemotherapeutic options are limited to investigational therapies at present. Therefore, adjuvant therapy for control of tumor recurrence and progression is of great interest, especially in skull base lesions where complete tumor resection is often not possible because of the proximity of cranial nerves. To understand the extent of genetic instability and associated chromosomal and gene losses or gains in skull base chordoma, we undertook whole-genome single-nucleotide polymorphism microarray analysis of flash frozen surgical chordoma specimens, 21 from the clivus and 1 from C1 to C2 vertebrae. We confirm the presence of a deletion at 9p involving CDKN2A, CDKN2B, and MTAP but at a much lower rate (22%) than previously reported for sacral chordoma. At a similar frequency (21%), we found aneuploidy of chromosome 3. Tissue microarray immunohistochemistry demonstrated absent or reduced fragile histidine triad (FHIT) protein expression in 98% of sacral chordomas and 67%of skull base chordomas. Our data suggest that chromosome 3 aneuploidy and epigenetic regulation of FHIT contribute to loss of the FHIT tumor suppressor in chordoma. The finding that FHIT is lost in a majority of chordomas provides new insight into chordoma pathogenesis and points to a potential new therapeutic target for this challenging neoplasm.

Baseline factors predictive of patient satisfaction with sacral neuromodulation for idiopathic fecal incontinence.

PubMed

Duelund-Jakobsen, Jakob; van Wunnik, Bart; Buntzen, Steen; Lundby, Lilli; Laurberg, Søren; Baeten, Cor

2014-07-01

Sacral neuromodulation (SNM) is an established treatment for fecal incontinence (FI). A recent study from our group found that the relationship between patient satisfaction and clinical outcome is complex and does not match the traditional used success criteria. Therefore, the ability to predict patient satisfaction must be given priority. The aim of the present study is to identify baseline factors predictive of patient satisfaction, with SNM, for idiopathic FI. We analyzed data from patients treated with SNM for idiopathic FI in Aarhus, Denmark, and Maastricht, The Netherlands. A questionnaire considering self-reported satisfaction was mailed to these patients and compared to baseline characteristics. Logistic regression was used to determine the predictive value of baseline demographic and diagnostic variables. In total, 131 patients were included in the analysis. Patient satisfaction with the current treatment result was reported in 75 patients. Fifty-six patients were dissatisfied with SNM treatment, after median 46 months (range 11-122) with permanent implantation. Pudendal nerve terminal motor latency (PNTML) was the solely identified predictor for long-term patient satisfaction. A subgroup univariate-logistic regression analysis showed that PNTML ≤ 2.3 ms at the side of lead implantation was a statistically significant predictor for patient satisfaction (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.01-5.24, p = 0.048). Baseline PNTML measurement may be predictive of long-term satisfaction with SNM therapy for idiopathic FI. Further studies are needed to confirm this result.

Meningitis-retention syndrome. An unrecognized clinical condition.

PubMed

Sakakibara, Ryuji; Uchiyama, Tomoyuki; Liu, Zhi; Yamamoto, Tatsuya; Ito, Takashi; Uzawa, Akiyuki; Suenaga, Tadahiro; Kanai, Kazuaki; Awa, Yusuke; Sugiyama, Yoshiki; Hattori, Takamichi

2005-12-01

A combination of acute urinary retention and aseptic meningitis has not been well known. This combination can be referred to as meningitis-retention syndrome (MRS), when accompanied by no other abnormalities. To describe the results of a uro-neurological assessment in our patients with MRS. In three patients (two men, one woman; age, 34-68 years), we performed urodynamic studies and relevant imaging and neurophysiological tests, in addition to cerebrospinal fluid (CSF) examination. All three patients developed acute urinary retention along with headache, fever and stiff neck. None had obvious neurological abnormalities, other than a slightly brisk reflex in the lower extremities. One had previously experienced generalized erythematous eruptions, but none had pain, hypalgesia or skin eruptions in the sacral dermatomes suggestive of Elsberg syndrome (infectious sacral polyradiculitis; mostly genital herpes). Brain/spinal/lumbar plexus MRI scans and nerve conduction studies were normal. CSF examination showed mild mononuclear pleocytosis, increased protein content, and normal to mildly decreased glucose content in all patients; increased myelin basic protein suggestive of central nervous system demyelination in one; and increased viral titers in none. Urodynamic study revealed, during the voiding phase, an underactive detrusor in all patients and an unrelaxing sphincter in one. These clinical manifestations were ameliorated within 3 weeks. We reported three cases of MRS, a peculiar syndrome that could be regarded as a mild variant of acute disseminated encephalomyelitis (ADEM). Urinary retention might reflect acute shock phase of this disorder. Although MRS has a benign and self-remitting course, management of the acute urinary retention is necessary.

Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a "safe" surgical corridor for sacro-iliac screw placement

PubMed Central

2011-01-01

Background Percutaneous sacro-iliac (SI) screw fixation represents a widely used technique in the management of unstable posterior pelvic ring injuries and sacral fractures. The misplacement of SI-screws under fluoroscopic guidance represents a critical complication for these patients. This study was designed to determine the prevalence of sacral dysmorphia and the radiographic anatomy of surgical S1 and S2 corridors in a representative trauma population. Methods Prospective observational cohort study on a consecutive series of 344 skeletally mature trauma patients of both genders enrolled between January 1, 2007, to September 30, 2007, at a single academic level 1 trauma center. Inclusion criteria included a pelvic CT scan as part of the initial diagnostic trauma work-up. The prevalence of sacral dysmorphia was determined by plain radiographic pelvic films and CT scan analysis. The anatomy of sacral corridors was analyzed on 3 mm reconstruction sections derived from multislice CT scan, in the axial, coronal, and sagittal plane. "Safe" potential surgical corridors at S1 and S2 were calculated based on these measurements. Results Radiographic evidence of sacral dysmorphia was detected in 49 patients (14.5%). The prevalence of sacral dysmorphia was not significantly different between male and female patients (12.2% vs. 19.2%; P = 0.069). In contrast, significant gender-related differences were detected with regard to radiographic analysis of surgical corridors for SI-screw placement, with female trauma patients (n = 99) having significantly narrower corridors at S1 and S2 in all evaluated planes (axial, coronal, sagittal), compared to male counterparts (n = 245; P < 0.01). In addition, the mean S2 body height was higher in dysmorphic compared to normal sacra, albeit without statistical significance (P = 0.06), implying S2 as a safe surgical corridor of choice in patients with sacral dysmorphia. Conclusions These findings emphasize a high prevalence of sacral dysmorphia in a representative trauma population and imply a higher risk of SI-screw misplacement in female patients. Preoperative planning for percutaneous SI-screw fixation for unstable pelvic and sacral fractures must include a detailed CT scan analysis to determine the safety of surgical corridors. PMID:21569232

Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a "safe" surgical corridor for sacro-iliac screw placement.

PubMed

Hasenboehler, Erik A; Stahel, Philip F; Williams, Allison; Smith, Wade R; Newman, Justin T; Symonds, David L; Morgan, Steven J

2011-05-10

Percutaneous sacro-iliac (SI) screw fixation represents a widely used technique in the management of unstable posterior pelvic ring injuries and sacral fractures. The misplacement of SI-screws under fluoroscopic guidance represents a critical complication for these patients. This study was designed to determine the prevalence of sacral dysmorphia and the radiographic anatomy of surgical S1 and S2 corridors in a representative trauma population. Prospective observational cohort study on a consecutive series of 344 skeletally mature trauma patients of both genders enrolled between January 1, 2007, to September 30, 2007, at a single academic level 1 trauma center. Inclusion criteria included a pelvic CT scan as part of the initial diagnostic trauma work-up. The prevalence of sacral dysmorphia was determined by plain radiographic pelvic films and CT scan analysis. The anatomy of sacral corridors was analyzed on 3 mm reconstruction sections derived from multislice CT scan, in the axial, coronal, and sagittal plane. "Safe" potential surgical corridors at S1 and S2 were calculated based on these measurements. Radiographic evidence of sacral dysmorphia was detected in 49 patients (14.5%). The prevalence of sacral dysmorphia was not significantly different between male and female patients (12.2% vs. 19.2%; P = 0.069). In contrast, significant gender-related differences were detected with regard to radiographic analysis of surgical corridors for SI-screw placement, with female trauma patients (n = 99) having significantly narrower corridors at S1 and S2 in all evaluated planes (axial, coronal, sagittal), compared to male counterparts (n = 245; P < 0.01). In addition, the mean S2 body height was higher in dysmorphic compared to normal sacra, albeit without statistical significance (P = 0.06), implying S2 as a safe surgical corridor of choice in patients with sacral dysmorphia. These findings emphasize a high prevalence of sacral dysmorphia in a representative trauma population and imply a higher risk of SI-screw misplacement in female patients. Preoperative planning for percutaneous SI-screw fixation for unstable pelvic and sacral fractures must include a detailed CT scan analysis to determine the safety of surgical corridors.

The Relationship Between Osteoarthritis of the Lumbar Facet Joints and Lumbosacropelvic Morphology.

PubMed

Sahin, Mehmet Sukru; Ergün, Adviye; Aslan, Akın

2015-10-01

Cross-sectional study. To investigate the relation between lumbosacropelvic morphology and the presence and degree of facet joint degeneration. Osteoarthritis of the facet joints is one of the most common degenerative changes in the spine. It is considered to be formed secondary to repetitive stress or trauma and spinal deformity with secondary overload. The cause(s) of facet joints osteoarthritis, however, have not been clearly identified. Abdominal computed tomography (CT) images of 723 patients which were taken between the years 2010 and 2014 were evaluated retrospectively. Patients with prior lumbar spinal surgery, serious congenital anomalies on CT, incomplete or complete lumbosacral transition, severe scoliosis, were excluded from the study. To eliminate the age- and sex-related differences in spinopelvic morphology, a study group was formed of the remaining subjects by including patients from a specific age group (30-35 yr) and same sex (females). For each patient the presence and grade of facet joint degeneration was investigated. In addition, pelvic incidence (PI), sacral slope and the angles of L1-L5 lumbar lordosis, sacral table, L5 vertebra posterior, and sacral kyphosis were measured for each patient. Sacral slope, sacral kyphosis, and L1-L5 lumbar lordosis angle were significantly higher in patients with osteoarthritic compared with normal subjects (P = 0.015, P = 0.018, P = 0.016). L5 vertebra posterior and sacral table angle were found to be significantly lower in patients with osteoarthritic than in normal subjects (P = 0.019, P = 0.007). The degree of facet joint degeneration was noticed to increase parallel to the decrease in the sacral table angle and L5 vertebra posterior angle, and to the increase in the L1-L5 lumbar lordosis, PI, and sacral slope. A close relation exists between the presence and degree of degeneration in the facet joint and lumbosacral pelvic morphology. Prevalence and degree of the degeneration in facet joint increases as the angle of sacral slope, L1-L5 lumbar lordosis, and PI increases or the angle of sacral table and L5 vertebra posterior decreases. 4.

Bell's Palsy as a Possible Complication of Hepatitis B Vaccination in A Child

PubMed Central

Tan, Hüseyin; Orbak, Zerrin

2009-01-01

Bell's Palsy is the sudden onset of unilateral temporary paralysis of facial muscles resulting from seventh cranial nerve dysfunction. Presented here is a two-year old female patient with right peripheral facial palsy following hepatitis B vaccination. Readers’ attention is drawn to an uncommon cause of Bell's Palsy, as a rare complication of hepatitis B vaccination. PMID:19902808

Consent for third molar tooth extractions in Australia and New Zealand: a review of current practice.

PubMed

Badenoch-Jones, E K; Lynham, A J; Loessner, D

2016-06-01

Informed consent is the legal requirement to educate a patient about a proposed medical treatment or procedure so that he or she can make informed decisions. The purpose of the study was to examine the current practice for obtaining informed consent for third molar tooth extractions (wisdom teeth) by oral and maxillofacial surgeons in Australia and New Zealand. An online survey was sent to 180 consultant oral and maxillofacial surgeons in Australia and New Zealand. Surgeons were asked to answer (yes/no) whether they routinely warned of a specific risk of third molar tooth extraction in their written consent. Seventy-one replies were received (39%). The only risks that surgeons agreed should be routinely included in written consent were a general warning of infection (not alveolar osteitis), inferior alveolar nerve damage (temporary and permanent) and lingual nerve damage (temporary and permanent). There is significant variability among Australian and New Zealand oral and maxillofacial surgeons regarding risk disclosure for third molar tooth extractions. We aim to improve consistency in consent for third molar extractions by developing an evidence-based consent form. © 2016 Australian Dental Association.

Facial reanimation with masseteric nerve: babysitter or permanent procedure? Preliminary results.

PubMed

Faria, Jose Carlos Marques; Scopel, Gean Paulo; Ferreira, Marcus Castro

2010-01-01

The authors are presenting a series of 10 cases of complete unilateral facial paralysis submitted to (I) end-to-end microsurgical coaptation of the masseteric branch of the trigeminal nerve and distal branches of the paralyzed facial nerve, and (II) cross-face sural nerve graft. The ages of the patients ranged from 5 to 63 years (mean: 44.1 years), and 8 (80%) of the patients were females. The duration of paralysis was no longer than 18 months (mean: 9.7 months). Follow-up varied from 6 to 18 months (mean: 12.6 months). Initial voluntary facial movements were observed between 3 and 6 months postoperatively (mean: 4.3 months). All patients were able to produce the appearance of a smile when asked to clench their teeth. Comparing the definition of the nasolabial fold and the degree of movement of the modiolus on both sides of the face, the voluntary smile was considered symmetrical in 8 cases. Recovery of the capacity to blink spontaneously was not observed. However, 8 patients were able to reduce or suspend the application of artificial tears. The authors suggest consideration of masseteric-facial nerve coaptation, whether temporary (baby-sitter) or permanent, as the principal alternative for reconstruction of facial paralysis due to irreversible nerve lesion with less than 18 months of duration.

Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores.

PubMed

Lin, Chin-Ta; Chen, Shih-Yi; Chen, Shyi-Gen; Tzeng, Yuan-Sheng; Chang, Shun-Cheng

2015-07-01

Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We present our experience of using parasacral perforator flaps in reconstructing sacral defects. Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator flap. The patients' sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded. There were 19 parasacral perforator flaps in this series. All flaps survived uneventfully except for 1 parasacral perforator flap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall flap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2-24 months). The average length of hospital stay was 20.7 days (range, 9-48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period. Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator flaps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator flap as a good choice for reconstructing sacral defects.

New Postcranial Material of the Early Caseid Casea broilii Williston, 1910 (Synapsida: Caseidae) with a Review of the Evolution of the Sacrum in Paleozoic Non-Mammalian Synapsids

PubMed Central

LeBlanc, Aaron R. H.; Reisz, Robert R.

2014-01-01

Here we use the description of a new specimen of the small caseid synapsid Casea broilii that preserves the sacral, pelvic and hind limb regions in great detail and in three dimensions, as a unique opportunity to reevaluate the early stages in the evolution of the sacrum in the lineage that led to mammals. We place this new material in the context of sacral evolution in early caseid synapsids and conclude that the transition from two to three sacral vertebrae occurred in small-bodied species, suggesting that it was not an adaptation to heavy weight bearing. Furthermore, we compare descriptions of sacral anatomy among known early synapsids, including caseids, ophiacodontids, edaphosaurids, varanopids, and sphenacodontians and review sacral evolution in early synapsids. Based on the descriptions of new species of caseids, edaphosaurids, and varanopids over the past several decades, it is clear that a sacrum consisting of three vertebrae evolved independently at least four times in synapsids during the Late Carboniferous and Early Permian. Furthermore, similarities in the morphologies of the sacral vertebrae and ribs of these early synapsids lead us to conclude that an anterior caudal vertebra had been incorporated into the sacral series convergently in these groups. Given the repeated acquisition of a three-vertebra sacrum in early synapsids and no apparent link to body size, we argue that this sacral anatomy was related to more efficient terrestrial locomotion than to increased weight bearing. PMID:25545624

A comparative, descriptive study of systemic factors and survival in elderly patients with sacral pressure ulcers.

PubMed

Jaul, Efraim; Menczel, Jacob

2015-03-01

Sacral pressure ulcers (PUs) are a serious complication in frail elderly patients. Thin tissue in the sacral area, low body mass index, and anatomical location contribute to the development of sacral PUs. A comparative, descriptive study was conducted to identify patient systemic factors associated with sacral PUs and to compare survival time in patients with and without PU. All consecutive patients with PUs (n = 77) and without sacral PUs (n = 53) admitted to the skilled nursing department of a geriatric hospital in Jerusalem, Israel between July 1, 2008 and December 31, 2011 were eligible to participate. Charts of previously admitted patients were abstracted and patients were prospectively followed until discharge, death, or the end of the study. Patient demographics, comorbidities, nutritional status, physical and cognitive function (measured using the Reisberg's Functional Assessment Staging Tool [FAST], Stages of Dementia of Alzheimer Scale, and the Glasgow Coma Scale), PU status, number of courses of antibiotic treatment during admission, length of hospitalization, and mortality were compared between patients admitted with and without a sacral PU using descriptive and univariate statistics. Logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for sacral PU versus without PU by study covariate. The association between sacral PU and survival time was assessed using Kaplan-Meier models. Patients with a sacral PU were significantly older (average age 81.60 ±10.78 versus 77.06±11.19 years old, P = 0.02) and had a higher prevalence of dementia (70% versus 30%, P = 0.007), Parkinson's disease (92.3% versus 7.7%, P = 0.03), and anemia (67.7% versus 32.3%, P = 0.06) than patients admitted without a PU. Patients with a sacral PU also had a lower body mass index (23.1 versus 25.4, P = 0.04), and lower hemoglobin (10.54 versus 11.11, P = 0.03), albumin (26.2 versus 29.7, P = 0.002), and total protein levels (61.3 versus 65.7, P = 0.04). In addition, antibiotic treatment was significantly higher in the patients with PU (50.6% versus 28.3%, P = 0.01). Patients with a sacral PU also had significantly lower physical and cognitive functioning scores and their median survival time was 70 days compared to 401 days in the non-PU group (P <0.001). These findings are generally consistent with the literature regarding risk factors for PU development and confirm the need for preventive measures. In addition, clinicians need to address the overall goal of patient care and patient quality of life when considering PU management interventions in this patient population.

Extremely Painful Multifocal Acquired Predominant Axonal Sensorimotor Neuropathy of the Upper Limb.

PubMed

Lieba-Samal, Doris; van Eijk, Jeroen J J; van Rosmalen, Marieke H J; van Balken, Irene M F; Verrips, Aad; Mostert, Jop; Pillen, Sigrid; van Alfen, Nens

2018-06-01

The differential diagnosis of upper extremity mononeuritis multiplex includes neuralgic amyotrophy, vasculitic neuropathy, and Lewis-Sumner syndrome. We describe 3 patients initially suspected of neuralgic amyotrophy, who had an extremely painful, protracted, progressive disease course, not fitting one of these established diagnoses. Nerve ultrasonography showed focal caliber changes of the roots, plexus, and limb nerves. Electromyography showed predominant multifocal axonopathy. Ongoing autoimmune neuropathy was suspected. Steroid treatment provided temporary relief, and intravenous immunoglobulin A sustained pain decrease and functional improvement. These patients appear to have extremely painful axonal inflammatory neuropathy, with a good response to immune-modulating treatment. © 2017 by the American Institute of Ultrasound in Medicine.

"Lucy" (A.L. 288-1) had five sacral vertebrae.

PubMed

Russo, Gabrielle A; Williams, Scott A

2015-02-01

A "long-backed" scenario of hominin vertebral evolution posits that early hominins possessed six lumbar vertebrae coupled with a high frequency of four sacral vertebrae (7:12-13:6:4), a configuration acquired from a hominin-panin last common ancestor (PLCA) having a vertebral formula of 7:13:6-7:4. One founding line of evidence for this hypothesis is the recent assertion that the "Lucy" sacrum (A.L. 288-1an, Australopithecus afarensis) consists of four sacral vertebrae and a partially-fused first coccygeal vertebra (Co1), rather than five sacral vertebrae as in modern humans. This study reassesses the number of sacral vertebrae in Lucy by reexamining the distal end of A.L.288-1an in the context of a comparative sample of modern human sacra and Co1 vertebrae, and the sacrum of A. sediba (MH2). Results demonstrate that, similar to S5 in modern humans and A. sediba, the last vertebra in A.L. 288-1an exhibits inferiorly-projecting (right side) cornua and a kidney-shaped inferior body articular surface. This morphology is inconsistent with that of fused or isolated Co1 vertebrae in humans, which either lack cornua or possess only superiorly-projecting cornua, and have more circularly-shaped inferior body articular surfaces. The level at which the hiatus' apex is located is also more compatible with typical five-element modern human sacra and A. sediba than if only four sacral vertebrae are present. Our observations suggest that A.L. 288-1 possessed five sacral vertebrae as in modern humans; thus, sacral number in "Lucy" does not indicate a directional change in vertebral count that can provide information on the PLCA ancestral condition. © 2015 Wiley Periodicals, Inc.

Fractures of the Sacrum After Chemoradiation for Rectal Carcinoma: Incidence, Risk Factors, and Radiographic Evaluation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kim, Han Jo; Boland, Patrick J.; Meredith, Dennis S.

Purpose: Sacral insufficiency fractures after adjuvant radiation for rectal carcinoma can present similarly to recurrent disease. As a complication associated with pelvic radiation, it is important to be aware of the incidence and risk factors associated with sacral fractures in the clinical assessment of these patients. Methods and Materials: Between 1998 and 2007, a total of 582 patients with locally advanced rectal carcinoma received adjuvant chemoradiation and surgical excision. Of these, 492 patients had imaging studies available for review. Hospital records and imaging studies from all 492 patients were retrospectively evaluated to identify risk factors associated with developing a sacralmore » insufficiency fracture. Results: With a median follow-up time of 3.5 years, the incidence of sacral fractures was 7.1% (35/492). The 4-year sacral fracture free rate was 0.91. Univariate analysis showed that increasing age ({>=}60 vs. <60 years), female sex, and history of osteoporosis were significantly associated with shorter time to sacral fracture (P=.01, P=.004, P=.001, respectively). There was no significant difference in the time to sacral fracture for patients based on stage, radiotherapy dose, or chemotherapy regimen. Multivariate analysis showed increasing age ({>=}60 vs. <60 years, hazard ratio [HR] = 2.50, 95% confidence interval [CI] = 1.22-5.13, P=.01), female sex (HR = 2.64, CI = 1.29-5.38, P=.008), and history of osteoporosis (HR = 3.23, CI = 1.23-8.50, P=.02) were independent risk factors associated with sacral fracture. Conclusions: Sacral insufficiency fractures after pelvic radiation for rectal carcinoma occur more commonly than previously described. Independent risk factors associated with fracture were osteoporosis, female sex, and age greater than 60 years.« less

Chordomas of the Skull Base, Mobile Spine, and Sacrum: An Epidemiologic Investigation of Presentation, Treatment, and Survival.

PubMed

Zuckerman, Scott L; Bilsky, Mark H; Laufer, Ilya

2018-05-01

Chordomas are rare primary bone tumors that arise from the axial skeleton. Our objective was to analyze trends in radiation and surgery over time and determine location-based survival predictors for chordomas of the skull base, mobile spine, and sacrum. A retrospective cohort study of the SEER (Surveillance Epidemiology and End Results) database from 1973 to 2013 was conducted. All patients had histologically confirmed chordomas. The principal outcome measure was overall survival (OS). The cohort included 1616 patients: skull base (664), mobile spine (444), and sacrum (508). Skull base tumors presented earliest in life (47.4 years) and sacral tumors presented latest (62.7 years). Rates of radiation remained stable for skull base and mobile spine tumors but declined for sacral tumors (P = 0.006). Rates of surgical resection remained stable for skull base and sacral tumors but declined for mobile spine tumors (P = 0.046). Skull base chordomas had the longest median survival (162 months) compared with mobile spine (94 months) and sacral tumors (87 months). Being married was independently associated with improved OS for skull base tumors (hazard ratio, 0.73; 95% confidence interval, 0.53-0.99; P = 0.044). Surgical resection was independently associated with improved OS for sacral chordomas (hazard ratio, 0.48; 95% confidence interval, 0.34-0.69; P < 0.001). Surgical resection for mobile spine chordomas and radiation for sacral chordomas decreased over time. Patients with skull base tumors survived longer than did patients with mobile spine and sacral chordomas, and surgical resection was associated with improved survival in sacral chordomas only. Understanding the behavior of these tumors can help cranial and spinal surgeons improve treatment in this patient population. Copyright © 2018 Elsevier Inc. All rights reserved.

Sacral neuromodulation and cardiac pacemakers.

PubMed

Roth, Ted M

2010-08-01

Potential for cross-talk between cardiac pacemakers and sacral neuromodulation remains speculative. We present a case series of patients with cardiac pacemakers who underwent staged Interstim (Medtronic, Minneapolis, MN) implantation and patients who had pulse generator implantation who later required cardiac pacemakers. No cross-talk was demonstrated in either group. Sacral neuromodulation appears to be safe in the setting of cardiac pacemakers without cardioversion/defibrillation technology.

Introduction of laparoscopic sacral colpopexy to a fellowship training program.

PubMed

Kantartzis, Kelly; Sutkin, Gary; Winger, Dan; Wang, Li; Shepherd, Jonathan

2013-11-01

Minimally invasive sacral colpopexy has increased over the past decade, with many senior physicians adopting this new skill set. However, skill acquisition at an academic institution in the presence of postgraduate learners is not well described. This manuscript outlines the introduction of laparoscopic sacral colpopexy to an academic urogynecology service that was not performing minimally invasive sacral colpopexies, and it also defines a surgical learning curve. The first 180 laparoscopic sacral colpopexies done by four attending urogynecologists from January 2009 to December 2011 were retrospectively analyzed. The primary outcome was operative time. Secondary outcomes included conversion to laparotomy, estimated blood loss, and intra- and postoperative complications. Linear regression was used to analyze trends in operative times. Fisher's exact test compared surgical complications and counts of categorical variables. Mean total operative time was 250 ± 52 min (range 146-452) with hysterectomy and 222 ± 45 (range 146-353) for sacral colpopexy alone. When compared with the first ten cases performed by each surgeon, operative times in subsequent groups decreased significantly, with a 6-16.3% reduction in overall times. There was no significant difference in the rate of overall complications regardless of the number of prior procedures performed (p = 0.262). Introduction of laparoscopic sacral colpopexy in a training program is safe and efficient. Reduction in operative time is similar to published learning curves in teaching and nonteaching settings. Introducing this technique does not add additional surgical risk as these skills are acquired.

Proximal sacral deformity: a common element in lytic isthmic spondylolisthesis at L5 and in degenerative spondylolisthesis at L4-L5 segment. Two apparently very different etiopathogenic entities.

PubMed

Gallego-Goyanes, A; Barahona-Lorenzo, D; Díez-Ulloa, M A

A radiographic study was carried out to investigate the relationship between proximal sacral sagittal anatomy (either kyphosis or lordosis) and either isthmic or degenerative spondylolisthesis. In addition, we studied whether there is a relationship between proximal sacral kyphosis and the degree of such listhesis in the case of L5 isthmic spondylolisthesis. Lateral standing x-rays were used from 173 patients, ninety of whom had degenerative spondylolisthesis L4-L5, and eighty-three an isthmic spondylolisthesis of L5 (67 low-grade and 16 high-grade) and compared with a control group of 100 patients adjusted by age and gender, without any type of spondylolisthesis. Listhesis was graded using Meyerding's classification and the proximal sacral kyphosis angle (CSP) was measured between S1 and S2 posterior walls, according to Harrison's method. In our series, there was a proximal sacral kyphosis in both types of spondylolisthesis, greater in the lytic type. By contrast, the control group had a proximal sacral lordosis. The differences were statistically significant. Therefore, we concluded that there was a proximal sacral kyphosis in patients with both degenerative and isthmic lytic spondylolisthesis, but with our results, we were not able to ascertain whether it is a cause or a consequence of this listhesis. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.

Evaluation of the diagnostic accuracy of four-view radiography and conventional computed tomography analysing sacral and pelvic fractures in dogs.

PubMed

Stieger-Vanegas, S M; Senthirajah, S K J; Nemanic, S; Baltzer, W; Warnock, J; Bobe, G

2015-01-01

The purpose of our study was (1) to determine whether four-view radiography of the pelvis is as reliable and accurate as computed tomography (CT) in diagnosing sacral and pelvic fractures, in addition to coxofemoral and sacroiliac joint subluxation or luxation, and (2) to evaluate the effect of the amount of training in reading diagnostic imaging studies on the accuracy of diagnosing sacral and pelvic fractures in dogs. Sacral and pelvic fractures were created in 11 canine cadavers using a lateral impactor. In all cadavers, frog-legged ventro-dorsal, lateral, right and left ventro-45°-medial to dorsolateral oblique frog leg ("rollover 45-degree view") radiographs and a CT of the pelvis were obtained. Two radiologists, two surgeons and two veterinary students classified fractures using a confidence scale and noted the duration of evaluation for each imaging modality and case. The imaging results were compared to gross dissection. All evaluators required significantly more time to analyse CT images compared to radiographic images. Sacral and pelvic fractures, specifically those of the sacral body, ischiatic table, and the pubic bone, were more accurately diagnosed using CT compared to radiography. Fractures of the acetabulum and iliac body were diagnosed with similar accuracy (at least 86%) using either modality. Computed tomography is a better method for detecting canine sacral and some pelvic fractures compared to radiography. Computed tomography provided an accuracy of close to 100% in persons trained in evaluating CT images.

Quantitative evaluation of the lumbosacral sagittal alignment in degenerative lumbar spinal stenosis

PubMed Central

Makirov, Serik K.; Jahaf, Mohammed T.; Nikulina, Anastasia A.

2015-01-01

Goal of the study This study intends to develop a method of quantitative sagittal balance parameters assessment, based on a geometrical model of lumbar spine and sacrum. Methods One hundred eight patients were divided into 2 groups. In the experimental group have been included 59 patients with lumbar spinal stenosis on L1-5 level. Forty-nine healthy volunteers without history of any lumbar spine pathlogy were included in the control group. All patients have been examined with supine MRI. Lumbar lordosis has been adopted as circular arc and described either anatomical (lumbar lordosis angle), or geometrical (chord length, circle segment height, the central angle, circle radius) parameters. Moreover, 2 sacral parameters have been assessed for all patients: sacral slope and sacral deviation angle. Both parameters characterize sacrum disposition in horizontal and vertical axis respectively. Results Significant correlation was observed between anatomical and geometrical lumbo-sacral parameters. Significant differences between stenosis group and control group were observed in the value of the “central angle” and “sacral deviation” parameters. We propose additional parameters: lumbar coefficient, as ratio of the lordosis angle to the segmental angle (Kl); sacral coefficient, as ratio of the sacral tilt (ST) to the sacral deviation (SD) angle (Ks); and assessment modulus of the mathematical difference between sacral and lumbar coefficients has been used for determining lumbosacral balance (LSB). Statistically significant differences between main and control group have been obtained for all described coefficients (p = 0.006, p = 0.0001, p = 0.0001, accordingly). Median of LSB value of was 0.18 and 0.34 for stenosis and control groups, accordingly. Conclusion Based on these results we believe that that spinal stenosis is associated with an acquired deformity that is measureable by the described parameters. It's possible that spinal stenosis occurs in patients with an LSB of 0.2 or less, so this value can be predictable for its development. It may suggest that spinal stenosis is more likely to occur in patients with the spinal curvature of this type because of abnormal distribution of the spine loads. This fact may have prognostic significance for develop vertebral column disease and evaluation of treatment results. PMID:26767160

Does sacral pulsed electromagnetic field therapy have a better effect than transcutaneous electrical nerve stimulation in patients with neurogenic overactive bladder?

PubMed

Fergany, Lamyaa A; Shaker, Husain; Arafa, Magdy; Elbadry, Mohamed S

2017-06-01

To compare the effectiveness of pulsed electromagnetic field therapy (PEMFT) and transcutaneous electrical nerve stimulation (TENS) on neurogenic overactive bladder dysfunction (OAB) in patients with spinal cord injury (SCI). In all, 80 patients [50 men and 30 women, with a mean (SD) age of 40.15 (8.76) years] with neurogenic OAB secondary to suprasacral SCI were included. They underwent urodynamic studies (UDS) before and after treatment. Patients were divided into two equal groups: Group A, comprised 40 patients who received 20 min of TENS (10 Hz with a 700 s generated pulse), three times per week for 20 sessions; Group B, comprised 40 patients who received PEMFT (15 Hz with 50% intensity output for 5 s/min for 20 min), three times per week for 20 sessions. In Group B, there was a significant increase in the maximum cystometric capacity ( P  < 0.001), volume at first uninhibited detrusor contraction ( P  < 0.002), and maximum urinary flow rate ( P  < 0.02). The UDS showed that the effects of PEMFT in patients with neurogenic OAB secondary to suprasacral SCI was better than TENS for inducing an inhibitory effect on neurogenic detrusor overactivity.

Nociceptive DRG neurons express muscle lim protein upon axonal injury.

PubMed

Levin, Evgeny; Andreadaki, Anastasia; Gobrecht, Philipp; Bosse, Frank; Fischer, Dietmar

2017-04-04

Muscle lim protein (MLP) has long been regarded as a cytosolic and nuclear muscular protein. Here, we show that MLP is also expressed in a subpopulation of adult rat dorsal root ganglia (DRG) neurons in response to axonal injury, while the protein was not detectable in naïve cells. Detailed immunohistochemical analysis of L4/L5 DRG revealed ~3% of MLP-positive neurons 2 days after complete sciatic nerve crush and maximum ~10% after 4-14 days. Similarly, in mixed cultures from cervical, thoracic, lumbar and sacral DRG ~6% of neurons were MLP-positive after 2 days and maximal 17% after 3 days. In both, histological sections and cell cultures, the protein was detected in the cytosol and axons of small diameter cells, while the nucleus remained devoid. Moreover, the vast majority could not be assigned to any of the well characterized canonical DRG subpopulations at 7 days after nerve injury. However, further analysis in cell culture revealed that the largest population of MLP expressing cells originated from non-peptidergic IB4-positive nociceptive neurons, which lose their ability to bind the lectin upon axotomy. Thus, MLP is mostly expressed in a subset of axotomized nociceptive neurons and can be used as a novel marker for this population of cells.

A study of HIV seropositivity with various clinical manifestation of herpes zoster among patients from Karnataka, India.

PubMed

Naveen, Kikkeri Narayanashetty; Tophakane, R S; Hanumanthayya, Keloji; Pv, Bhagawat; Pai, Varadraj V

2011-12-15

To study the various clinical presentations of herpes zoster and to find out the proportion of HIV positivity in these patients. A time bound study was conducted from November 2004 to October 2005. All clinically diagnosed cases of herpes zoster were tested for HIV infection with ELISA and confirmed by Tridot and Coomb AID. Total numbers of 90 zoster cases were recorded. Mean duration of pre herpetic neuralgia was 2.134 (standard deviation=1.424, F=8.951, P<0.001). The thoracic dermatome (46.66%) was most commonly involved, followed by the cranial nerves (18.88%), lumbar (14.44%), cervical (13.33%) and sacral (6.66%) nerves. A substantial proportion, 34 (37.77%) out of 90 cases, were found to be HIV positive. Of these, 64.7 percent of the HIV seropositive herpes zoster patients belonged to the age group of 21-40 years. Out of 39 who had a risk of exposure to STDs and whose ages were less than 50 years, 31 (79.48%) tested positive for HIV infection. The occurrence of zoster in the young age group in patients who report a history of risk factors for HIV, may need testing. Herpes zoster serves as a clinical indicator of HIV seropositivity and one of the earliest manifestations.

Percutaneous nerve evaluation (PNE) for treatment of non-obstructive urinary retention: urodynamic changes, placebo effects, and response rates.

PubMed

Sharifiaghdas, Farzaneh; Mirzaei, Mahboubeh; Ahadi, Babak

2014-03-04

To evaluate the results of percutaneous nerve evaluation (PNE) implantation in the treatment of non-obstructive urinary retention and report the changes in the urodynamic parameters. Patients with non-obstructive urinary retention or incomplete bladder emptying were included. All patients filled a 7 days voiding diary chart and underwent PNE for one week, and the patient was asked to record the second voiding diary chart and repeat urodynamic study in this period. Then the PNE lead was removed from the S3 foramen, but the connections remained fixed in place for another 3 days to exclude the placebo effects and the third voiding diary chart was completed by the patient. The patient wasn't aware of lead removal. Success was defined as, more than 50% improvement in at least one of the urinary tract symptoms. Forty five patients with a mean age of 37.1 years (ranged 9-83 years) were treated with PNE for refractory, non-obstructive urinary retention. Of study subjects 28 complained from complete urinary retention, and 17 had incomplete emptying. Of participants, 28 (62.2%) demonstrated greater than 50% improvement in the urinary symptoms. Urodynamic data, showed a statistically significant increase in maximum flow rate (8 ± 2.2 mL/sec to 16 ± 3.6 mL/sec, P = .06) and voided volume (35 mL to 187 mL, P = .032) in the responders. Any placebo effects in PNE have not been seen. Patients with complete non obstructive urinary retention were good responders to PNE. The placebo effect in sacral nerve stimulation was negligible.

First branchial cleft anomalies in children: Experience with 30 cases.

PubMed

Li, Wanpeng; Zhao, Liming; Xu, Hongming; Li, Xiaoyan

2017-07-01

First branchial cleft anomalies (FBCA) are rare in the clinical setting, as they account for 1 to 8% of all branchial abnormalities. The purpose of this study is to explore the relationship between the fistula tract and facial nerve and the surgical method of FBCA. This retrospective study included 30 cases of FBCA in children managed from 2009 to 2016. All patients underwent surgery to remove the tract of the FBCA. We reviewed the clinical data of the patients to obtain their demographics and management. Thirty patients (11 male and 19 female) with anomalies of FBCA were diagnosed. The ages ranged from 1 to 13 years (median, 3 years). Twenty cases had a close relationship with the parotid gland. The facial nerve was identified in 20 of the 30 patients. The tract ran deep to the facial nerve in 3 cases, superficial to it in 21 cases, and passed between the branches of the nerve in 6 cases. The facial nerve was not identified in ten patients, as the tract was superficial to it. There were 2 cases of postoperative temporary facial paralysis (2/30, 6.7%). The symptoms gradually improved after one month, 1 case had permanent facial paralysis (1/30, 3.3%), and 1 case had postoperative recurrence. Complete excision of the tract is the only way to manage FBCA, and the course of the tracts vary and have different relationships with the facial nerve. There are 3 types: Superficial, deep to the facial nerve, and between the branches of the nerve. Therefore, surgical approaches differ among the various types, and careful preoperative planning and protecting the facial nerve during resection of the tract are essential.

First branchial cleft anomalies in children: Experience with 30 cases

PubMed Central

Li, Wanpeng; Zhao, Liming; Xu, Hongming; Li, Xiaoyan

2017-01-01

First branchial cleft anomalies (FBCA) are rare in the clinical setting, as they account for 1 to 8% of all branchial abnormalities. The purpose of this study is to explore the relationship between the fistula tract and facial nerve and the surgical method of FBCA. This retrospective study included 30 cases of FBCA in children managed from 2009 to 2016. All patients underwent surgery to remove the tract of the FBCA. We reviewed the clinical data of the patients to obtain their demographics and management. Thirty patients (11 male and 19 female) with anomalies of FBCA were diagnosed. The ages ranged from 1 to 13 years (median, 3 years). Twenty cases had a close relationship with the parotid gland. The facial nerve was identified in 20 of the 30 patients. The tract ran deep to the facial nerve in 3 cases, superficial to it in 21 cases, and passed between the branches of the nerve in 6 cases. The facial nerve was not identified in ten patients, as the tract was superficial to it. There were 2 cases of postoperative temporary facial paralysis (2/30, 6.7%). The symptoms gradually improved after one month, 1 case had permanent facial paralysis (1/30, 3.3%), and 1 case had postoperative recurrence. Complete excision of the tract is the only way to manage FBCA, and the course of the tracts vary and have different relationships with the facial nerve. There are 3 types: Superficial, deep to the facial nerve, and between the branches of the nerve. Therefore, surgical approaches differ among the various types, and careful preoperative planning and protecting the facial nerve during resection of the tract are essential. PMID:28672934

Chronic Localized Back Pain Due to Posterior Cutaneous Nerve Entrapment Syndrome (POCNES): A New Diagnosis.

PubMed

Boelens, Oliver B; Maatman, Robert C; Scheltinga, Marc R; van Laarhoven, Kees; Roumen, Rudi M

2017-03-01

Most patients with chronic back pain suffer from degenerative thoracolumbovertebral disease. However, the following case illustrates that a localized peripheral nerve entrapment must be considered in the differential diagnosis of chronic back pain. We report the case of a 26-year-old woman with continuous excruciating pain in the lower back area. Previous treatment for nephroptosis was to no avail. On physical examination the pain was present in a 2 x 2 cm area overlying the twelfth rib some 4 cm lateral to the spinal process. Somatosensory testing using swab and alcohol gauze demonstrated the presence of skin hypo- and dysesthesia over the painful area. Local pressure on this painful spot elicited an extreme pain response that did not irradiate towards the periphery. These findings were highly suggestive of a posterior version of the anterior cutaneous nerve entrapment syndrome (ACNES), a condition leading to a severe localized neuropathic pain in anterior portions of the abdominal wall. She demonstrated a beneficial albeit temporary response after lidocaine infiltration as dictated by an established diagnostic and treatment protocol for ACNES. She subsequently underwent a local neurectomy of the involved superficial branch of the intercostal nerve. This limited operation had a favorable outcome resulting in a pain-free return to normal activities up to this very day (follow-up of 24 months).We propose to name this novel syndrome "posterior cutaneous nerve entrapment syndrome" (POCNES). Each patient with chronic localized back pain should undergo simple somatosensory testing to detect the presence of overlying skin hypo- and dysesthesia possibly reflecting an entrapped posterior cutaneous nerve.Key words: Chronic pain, back pain, posterior cutaneous nerve entrapment, peripheral nerve entrapment, surgical treatment for pain, anterior cutaneous nerve entrapment.

Jacob's limp.

PubMed

Hoenig, L J

1997-02-01

This study describes in modern medical terms a traumatic hip injury suffered by the Biblical patriarch Jacob approximately 3,500 years ago. The case history is based on the original Hebrew text found in the Bible book of Genesis (Chapter 32:25-33) as interpreted by traditional Jewish commentaries on the Bible. Jacob sustained a hip injury in hand-to-hand combat with an adversary or through an intense physiological reaction to a prophetic vision of such a battle. He appears to have sustained neurological injury to his sciatic nerve as well as musculoskeletal damage to his hip. These injuries caused a temporary limping gait. Jacob probably sustained a neurapraxia of the sciatic nerve. The differential diagnosis of his musculoskeletal hip injury includes hip dislocation, fracture, soft tissue trauma, and articular pathology.

Clinical outcomes of pulsed radiofrequency neuromodulation for the treatment of occipital neuralgia.

PubMed

Choi, Hyuk Jai; Oh, In Ho; Choi, Seok Keun; Lim, Young Jin

2012-05-01

Occipital neuralgia is characterized by paroxysmal jabbing pain in the dermatomes of the greater or lesser occipital nerves caused by irritation of these nerves. Although several therapies have been reported, they have only temporary therapeutic effects. We report the results of pulsed radiofrequency treatment of the occipital nerve, which was used to treat occipital neuralgia. Patients were diagnosed with occipital neuralgia according to the International Classification of Headache Disorders classification criteria. We performed pulsed radiofrequency neuromodulation when patients presented with clinical findings suggestive occipital neuralgia with positive diagnostic block of the occipital nerves with local anesthetics. Patients were analyzed according to age, duration of symptoms, surgical results, complications and recurrence. Pain was measured every month after the procedure using the visual analog and total pain indexes. From 2010, ten patients were included in the study. The mean age was 52 years (34-70 years). The mean follow-up period was 7.5 months (6-10 months). Mean Visual Analog Scale and mean total pain index scores declined by 6.1 units and 192.1 units, respectively, during the follow-up period. No complications were reported. Pulsed radiofrequency neuromodulation of the occipital nerve is an effective treatment for occipital neuralgia. Further controlled prospective studies are necessary to evaluate the exact effects and long-term outcomes of this treatment method.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment.

PubMed

Yousefshahi, Fardin; Predescu, Oana; Colizza, Melissa; Asenjo, Juan Francisco

2016-01-01

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels-from peripheral branches on the diaphragm to its entrance in the cervical spine-could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Pelvic trauma with displaced sacral fractures: functional outcome at one year.

PubMed

Tötterman, Anna; Glott, Thomas; Søberg, Helene Lundgaard; Madsen, Jan Erik; Røise, Olav

2007-06-01

A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with displaced sacral fractures. To describe the medium term functional outcome in unstable sacral fractures. Displaced sacral fractures pose a special challenge in orthopedic surgery due to the high rate of associated injuries. Little information is available on the medium-term functional outcome of patients with injuries which include unstable sacral fractures. We examined 31 patients with displaced sacral fractures having 10 mm or more displacement, 1 year (mean, 1.4 years; range, 1.0-2.5 years) after injury. Data from a previous study were supplemented with functional outcome measures (work status, independence in ADL, and SF-36). An association between outcome and tested variables was sought. Fifteen months after injury, 65% of the patients had regained their independence in functions pertaining to daily activities; 33% had returned to work. All dimensions of perceived health were affected. Polytrauma and impairments relative to voiding and sexual function had a detrimental effect on outcome. Fracture characteristics were not predictive of poor outcome. Although the majority of patients achieved independent living, medium-term follow-up indicated significant residual disability. The complex nature of these fractures and the associated injuries should be considered in the rehabilitation of these patients.

Anterior sacral meningocele with presacral cysts: report of a case.

PubMed

Krivokapić, Zoran; Grubor, Nikica; Micev, Marjan; Colović, Radoje

2004-11-01

Anterior sacral meningocele is a rare anomaly most frequently presenting as a presacral mass. Since the first description in 1837, approximately 150 cases have been reported. The case presented is a 37-year-old female in whom an asymptomatic presacral mass was discovered during her first delivery. Because normal delivery was impossible, a cesarean section was performed. A year later, in a regional hospital a "cystic presacral tumor" was treated with biopsy and drainage. Four years later, she developed constipation caused by perineal compression for which she was admitted to our department in which two anterior presacral cysts were excised. The recovery was complicated with meningitis, which was successfully treated with antibiotics. Whenever a presacral mass is found, anterior sacral meningocele has to be a diagnostic consideration. The symptoms are usually related to the compression on rectum, bladder, and sacral nervous plexus. Rectal examination and radiography of the pelvis with the sacral bone showing the "scimitar sign" are the main diagnostic methods. Myelography, computed tomography, and magnetic resonance imaging are the best methods for identifying the precise anatomy of sacral meningocele and for proper planning of the operation. Transvaginal or transrectal aspiration and drainage are not advised, because they may result in a lethal outcome caused by sepsis.

Intrapartum sacral stress fracture due to pregnancy-related osteoporosis: a case report.

PubMed

Oztürk, Gülcan; Külcü, Duygu Geler; Aydoğ, Ece

2013-01-01

Low back pain (LBP) and hip pain frequently occur during pregnancy and postpartum period. Although pelvic and mechanic lesions of the soft tissues are most responsible for the etiology, sacral fracture is also one of the rare causes. A 32-year-old primigravid patient presented with LBP and right hip pain which started 3 days after vaginal delivery. Although direct radiographic examination was normal, magnetic resonance imaging of the sacrum revealed sacral stress fracture. Lumbar spine and femoral bone mineral density showed osteoporosis as a risk factor. There were no other risk factors such as trauma, excessive weight gain, and strenuous physical activity. It is considered that the patient had sacral fatigue and insufficiency fracture in intrapartum period. The patient's symptoms subsided in 3 months after physical therapy and rest. In conclusion, sacral fractures during pregnancy and postpartum period, especially resulting from childbirth, are very rare. To date, there are two cases in the literature. In cases who even do not have risk factors related to vaginal delivery such as high birth weight infant and the use of forceps, exc., sacral fracture should be considered in the differential diagnosis of LBP and hip pain started soon after child birth. Pregnancy-related osteoporosis may lead to fracture during vaginal delivery.

Evaluation of the rostral projection of the sacral lamina as a component of degenerative lumbosacral stenosis in German shepherd dogs.

PubMed

Saunders, Harvey; Worth, Andrew J; Bridges, Janis P; Hartman, Angela

2018-05-20

To determine the association between a greater rostral projection of the sacral lamina and clinical signs of cauda equina syndrome (CES) in German shepherd dogs (GSD) with presumptive degenerative lumbosacral disease (DLSS). Retrospective cohort study. One hundred forty-three GSD (125 police dogs and 18 pet dogs) presenting for either CES or prebreeding evaluation. Fifty-five were classified as affected by CES and diagnosed with DLSS, and 88 were classified as unaffected on the basis of clinical and imaging findings. The position of the rostral edge of the sacral lamina was measured from radiographs and/or computed tomography (CT) scans. This position was compared between affected and unaffected dogs. In dogs that underwent both radiography and CT scanning, the agreement between sacral lamina localization using each imaging modality was determined. Owners/handlers were contacted to determine whether dogs subsequently developed clinical signs compatible with CES at a mean of 29 months (unaffected). The sacral lamina did not extend as far rostrally in affected dogs, compared to unaffected dogs (P = .04). Among the 88 dogs unaffected by CES at initial evaluation, 2 developed clinical signs consistent with CES at follow-up. Rostral projection of the sacral lamina, previously proposed as a potential risk factor in dogs with CES due to lumbosacral degeneration, was not associated with a diagnosis of DLSS in this study; the opposite was true. Rostral projection of the sacral lamina may not be a predisposing factor in the development of CES due to DLSS in GSD. © 2018 The American College of Veterinary Surgeons.

Comparative sacral morphology and the reconstructed tail lengths of five extinct primates: Proconsul heseloni, Epipliopithecus vindobonensis, Archaeolemur edwardsi, Megaladapis grandidieri, and Palaeopropithecus kelyus.

PubMed

Russo, Gabrielle A

2016-01-01

This study evaluated the relationship between the morphology of the sacrum-the sole bony link between the tail or coccyx and the rest of the body-and tail length (including presence/absence) and function using a comparative sample of extant mammals spanning six orders (Primates, Carnivora, Rodentia, Diprotodontia, Pilosa, Scandentia; N = 472). Phylogenetically-informed regression methods were used to assess how tail length varied with respect to 11 external and internal (i.e., trabecular) bony sacral variables with known or suspected biomechanical significance across all mammals, only primates, and only non-primates. Sacral variables were also evaluated for primates assigned to tail categories ('tailless,' 'nonprehensile short-tailed,' 'nonprehensile long-tailed,' and 'prehensile-tailed'). Compared to primates with reduced tail lengths, primates with longer tails generally exhibited sacra having larger caudal neural openings than cranial neural openings, and last sacral vertebrae with more mediolaterally-expanded caudal articular surfaces than cranial articular surfaces, more laterally-expanded transverse processes, more dorsally-projecting spinous processes, and larger caudal articular surface areas. Observations were corroborated by the comparative sample, which showed that shorter-tailed (e.g., Lynx rufus [bobcat]) and longer-tailed (e.g., Acinonyx jubatus [cheetah]) non-primate mammals morphologically converge with shorter-tailed (e.g., Macaca nemestrina) and longer-tailed (e.g., Macaca fascicularis) primates, respectively. 'Prehensile-tailed' primates exhibited last sacral vertebrae with more laterally-expanded transverse processes and greater caudal articular surface areas than 'nonprehensile long-tailed' primates. Internal sacral variables performed poorly compared to external sacral variables in analyses of extant primates, and were thus deemed less useful for making inferences concerning tail length and function in extinct primates. The tails lengths of five extinct primates were reconstructed from the external sacral variables: Archaeolemur edwardsi had a 'nonprehensile long tail,' Megaladapis grandidieri, Palaeopropithecus kelyus, and Epipliopithecus vindobonensis probably had 'nonprehensile short tails,' and Proconsul heseloni was 'tailless.' Copyright © 2015 Elsevier Ltd. All rights reserved.

Sacroplasty for symptomatic sacral hemangioma: a novel treatment approach. A case report.

PubMed

Agarwal, V; Sreedher, G; Weiss, K R; Hughes, M A

2013-06-01

Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty. A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma. Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications.

Sacroplasty for Symptomatic Sacral Hemangioma: A Novel Treatment Approach

PubMed Central

Agarwal, V.; Sreedher, G.; Weiss, K.R.; Hughes, M.A.

2013-01-01

Summary Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty. A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma. Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications. PMID:23693051

Long-term effect of sphincteric fatigue during bladder neurostimulation.

PubMed

Li, J S; Hassouna, M; Sawan, M; Duval, F; Elhilali, M M

1995-01-01

Commercially available stimulators lack several features, including multiple channel capability and flexible stimulation parameters. These factors limit clinical application. A new computerized electrical stimulator system was developed by our team and evaluated for its efficacy in bladder evacuation in an animal model after spinal cord transection. The system can generate a wide range of stimulation characteristics and has the feature of being a programmable multichannel pacemaker. It has enabled us to induce a reversible fatigue to the external sphincter that results in proper bladder emptying on stimulation. Using this new bladder pacemaker, 8 dogs were studied. We applied the concept of fatiguing of the external sphincter via the pudendal nerve to avoid rhizotomy. We determined the optimal stimulation parameters that can reliably empty the dog's bladder for the duration of the experiment, which lasted for 8 months. The new computerized electrical stimulation system achieved the objective of reducing bladder outlet resistance without the need for sacral rhizotomy.

Bovine herpes virus infections in cattle.

PubMed

Nandi, S; Kumar, Manoj; Manohar, M; Chauhan, R S

2009-06-01

Bovine herpes virus 1 (BHV-1) is primarily associated with clinical syndromes such as rhinotracheitis, pustular vulvovaginitis and balanoposthitis, abortion, infertility, conjunctivitis and encephalitis in bovine species. The main sources of infection are the nasal exudates and the respiratory droplets, genital secretions, semen, fetal fluids and tissues. The BHV-1 virus can become latent following a primary infection with a field isolate or vaccination with an attenuated strain. The viral genomic DNA has been demonstrated in the sensory ganglia of the trigeminal nerve in infectious bovine rhinotracheitis (IBR) and in sacral spinal ganglia in pustular vulvovaginitis and balanoposthitis cases. BHV-1 infections can be diagnosed by detection of virus or virus components and antibody by serological tests or by detection of genomic DNA by polymerase chain reaction (PCR), nucleic acid hybridization and sequencing. Inactivated vaccines and modified live virus vaccines are used for prevention of BHV-1 infections in cattle; subunit vaccines and marker vaccines are under investigation.

Genital herpes simplex virus infection: clinical course and attempted therapy.

PubMed

Davis, L G; Keeney, R E

1981-06-01

The epidemiology, clinical course, diagnosis, and attempted treatments of herpes genitalis are reviewed. Herpes genitalis is an increasingly common sexually transmitted disease for which there is no effective treatment. It can occur in either sex and is mot commonly first found in patients 14 to 29 years old. Initial exposure to the virus may result in prolonged local symptoms (pain, itching, discharge) and signs (ulcerative lesions) as well as fever, malaise, myalgias, and fatigue. After the initial exposure, the virus may be found in a latent stage in the dorsal nerve root ganglia in the sacral area, and recurrences of disease may ensue. The frequency and clinical course of recurrent genital herpes can be of varying duration and severity. Although antiviral substances, immune potentiators, topical surfactants, and photodynamic inactivation have been used to treat genital herpes infections, there is no proven effective therapy.

Epidemiology of shingles.

PubMed

Glynn, C; Crockford, G; Gavaghan, D; Cardno, P; Price, D; Miller, J

1990-10-01

One thousand and nineteen patients with acute varicella zoster viral infection were referred to the physiotherapy department for treatment between 1978 and 1986. Sixty per cent were women and 40% were men with a mean age of 58 years (range 9-96 years). The prevalence varied between 1.3 and 1.6 per 1000 per annum. The left side was affected in 52% while the right was affected in 48%. The thoracic dermatomes were the most commonly affected (56%) followed by cervical (17%), lumbar (10%), sacral (5%), and the trigeminal nerve was infected in 12%. There was a significant seasonal (P less than 0.001) variation in the prevalence of acute varicella zoster virus infection, most common in the summer and least common in the spring. There was no clustering in time and space so that it is unlikely that the varicella zoster virus is infective or that re-exposure to the virus causes reactivation of the latent virus.

Slow transit constipation: a review of a colonic functional disorder.

PubMed

Frattini, Jared C; Nogueras, Juan J

2008-05-01

Constipation is a common gastrointestinal complaint that can cause significant physical and psychosocial problems. It has been categorized as slow transit constipation, normal transit constipation, and obstructed defecation. Both the definition and pathophysiology of constipation are unclear, but attempts to describe each of the three types have been made. Slow transit constipation, a functional colonic disorder represents approximately 15 to 30% of constipated patients. The theorized etiologies are disorders of the autonomic and enteric nervous system and/or a dysfunctional neuroendocrine system. Slow transit constipation can be diagnosed with a complete history, physical exam, and a battery of specific diagnostic studies. Once the diagnosis is affirmed and medical management has failed, there are several treatment options. Biofeedback, sacral nerve stimulation, segmental colectomy, and subtotal colectomy with various anastomoses have all been used. Of those treatment options, a subtotal colectomy with ileorectal anastomosis is the most efficacious with the data to support its use.

[Four cases of urinary dysfunction associated with sacral herpes zoster].

PubMed

Matsuo, Tomohiro; Oba, Kojiro; Miyata, Yasuyoshi; Igawa, Tsukasa; Sakai, Hideki

2014-02-01

Herpes zoster is caused by the infection of Varicella-Zoster virus. The anatomical distribution of herpes zoster in the sacral area is only 6. 9%1). Moreover, the onset rate of herpes zoster with urinary dysfunction is 0.6%1). The lesion sites of herpes zoster which cause urinary dysfunction are almost lumber and sacral areas. We describe four cases of sacral herpes zoster with urinary dysfunction in this report. All patients were elderly people (66-84 years old), and all patients were administered anti-virus drugs and alpha 1-adrenergic receptor blockers. Because of urinary retention, three patients have performed clean intermittent self-catheterization (CIC) for several weeks. As the lesions of herpes zoster healed, each patient recovered from urinary dysfunction.

Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra.

PubMed

Hwang, John S; Reilly, Mark C; Shaath, Mohammad K; Changoor, Stuart; Eastman, Jonathan; Routt, Milton Lee Chip; Sirkin, Michael S; Adams, Mark R

2018-04-01

To quantify the osseous anatomy of the dysmorphic third sacral segment and assess its ability to accommodate internal fixation. Retrospective chart review of a trauma database. University Level 1 Trauma Center. Fifty-nine patients over the age of 18 with computed tomography scans of the pelvis separated into 2 groups: a group with normal pelvic anatomy and a group with sacral dysmorphism. The sacral osseous area was measured on computed tomography scans in the axial, coronal, and sagittal planes in normal and dysmorphic pelves. These measurements were used to determine the possibility of accommodating a transiliac transsacral screw in the third sacral segment. In the normal group, the S3 coronal transverse width averaged 7.71 mm and the S3 axial transverse width averaged 7.12 mm. The mean S3 cross-sectional area of the normal group was 55.8 mm. The dysmorphic group was found to have a mean S3 coronal transverse width of 9.49 mm, an average S3 axial transverse width of 9.14 mm, and an S3 cross-sectional area of 77.9 mm. The third sacral segment of dysmorphic sacra has a larger osseous pathway available to safely accommodate a transiliac transsacral screw when compared with normal sacra. The S3 segment of dysmorphic sacra can serve as an additional site for screw placement when treating unstable posterior pelvic ring fractures.

Enhancement of the intrinsic defecation reflex by mosapride, a 5-HT4 agonist, in chronically lumbosacral denervated guinea pigs.

PubMed

Kojima, Yu; Fujii, Hisao; Katsui, Renta; Nakajima, Yoshiyuki; Takaki, Miyako

2006-10-01

The defecation reflex is composed of rectal distension-evoked rectal (R-R) reflex contractions and synchronous internal anal sphincter (R-IAS) reflex relaxations in guinea pigs. These R-R and R-IAS reflexes are controlled via extrinsic sacral excitatory nerve pathway (pelvic nerves), lumbar inhibitory nerve pathways (colonic nerves) and by intrinsic cholinergic excitatory and nitrergic inhibitory nerve pathways. The effect of mosapride (a prokinetic benzamide) on the intrinsic reflexes, mediated via enteric 5-HT(4) receptors, was evaluated by measuring the mechanical activity of the rectum and IAS in anesthetized guinea pigs using an intrinsic R-R and R-IAS reflex model resulting from chronic (two to nine days) lumbosacral denervation (PITH). In this model, the myenteric plexus remains undamaged and the distribution of myenteric and intramuscular interstitial cells of Cajal is unchanged. Although R-R and R-IAS reflex patterns markedly changed, the reflex indices (reflex pressure or force curve-time integral) of both the R-R contractions and the synchronous R-IAS relaxations were unchanged. The frequency of the spontaneous R and IAS motility was also unchanged. Mosapride (0.1-1.0 mg/kg) dose-dependently increased both intrinsic R-R (maximum: 1.82) and R-IAS reflex indices (maximum: 2.76) from that of the control (1.0) 6-9 days following chronic PITH. The dose-response curve was similar to that in the intact guinea pig, and had shifted to the left from that in the guinea pig after acute PITH. A specific 5-HT(4) receptor antagonist, GR 113808 (1.0 mg/kg), decreased both reflex indices by approximately 50% and antagonized the effect of mosapride 1.0 mg/kg. This was quite different from the result in the intact guinea pig where GR 113808 (1.0 mg/kg) did not affect either of the reflex indices. The present results indicate that mosapride enhanced the intrinsic R-R and R-IAS reflexes and functionally compensated for the deprivation of extrinsic innervation. The actions of mosapride were mediated through endogenously active, intrinsic 5-HT(4) receptors which may be post-synaptically located in the myenteric plexus of the anorectum.

Stretching of roots contributes to the pathophysiology of radiculopathies.

PubMed

Berthelot, Jean-Marie; Laredo, Jean-Denis; Darrieutort-Laffite, Christelle; Maugars, Yves

2018-01-01

To perform a synthesis of articles addressing the role of stretching on roots in the pathophysiology of radiculopathy. Review of relevant articles on this topic available in the PubMed database. An intraoperative microscopy study of patients with sciatica showed that in all patients the hernia was adherent to the dura mater of nerve roots. During the SLR (Lasègue's) test, the limitation of nerve root movement occurs by periradicular adhesive tissue, and temporary ischemic changes in the nerve root induced by the root stretching cause transient conduction disturbances. Spinal roots are more frail than peripheral nerves, and other mechanical stresses than root compression can also induce radiculopathy, especially if they also impair intraradicular blood flow, or the function of the arachnoid villi intimately related to radicular veins. For instance arachnoiditis, the lack of peridural fat around the thecal sac, and epidural fibrosis following surgery, can all promote sciatica, especially in patients whose sciatic trunks also stick to piriformis or internus obturator muscles. Indeed, stretching of roots is greatly increased by adherence at two levels. As excessive traction of nerve roots is not shown by imaging, many physicians have unlearned to think in terms of microscopic and physiologic changes, although nerve root compression in the lumbar MRI is lacking in more than 10% of patients with sciatica. It should be reminded that, while compression of a spinal nerve root implies stretching of this root, the reverse is not true: stretching of some roots can occur without any visible compression. Copyright © 2017 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.

Dual-dermal-barrier fashion flaps for the treatment of sacral pressure sores.

PubMed

Hsiao, Yen-Chang; Chuang, Shiow-Shuh

2015-02-01

The sacral region is one of the most vulnerable sites for the development of pressure sores. Even when surgical reconstruction is performed, there is a high chance of recurrence. Therefore, the concept of dual-dermal-barrier fashion flaps for sacral pressure sore reconstruction was proposed. From September 2007 to June 2010, nine patients with grade IV sacral pressures were enrolled. Four patients received bilateral myocutaneous V-Y flaps, four patients received bilateral fasciocutaneous V-Y flaps, and one patient received bilateral rotation-advanced flaps for sacral pressure reconstruction. The flaps were designed based on the perforators of the superior gluteal artery in one patient's reconstructive procedure. All flaps' designs were based on dual-dermal-barrier fashion. The mean follow-up time was 16 months (range = 12-25). No recurrence was noted. Only one patient had a complication of mild dehiscence at the middle suture line, occurring 2 weeks after the reconstructive surgery. The dual-dermal fashion flaps are easily duplicated and versatile. The study has shown minimal morbidity and a reasonable outcome.

Pudendal nerve neuromodulation with neurophysiology guidance: a potential treatment option for refractory chronic pelvi-perineal pain.

PubMed

Carmel, Maude; Lebel, Michel; Tu, Le Mai

2010-05-01

Refractory chronic pelvi-perineal pain (RCPPP) is a challenging entity that has devastating consequences for patient's quality of life. Many etiologies have been proposed including pudendal neuralgia. Multiple treatment options are used but the reported results are sub-optimal and temporary. In this article, we present the technique of pudendal nerve neuromodulation with neurophysiology guidance as a treatment option for RCPPP. This technique is a two-step procedure that includes electrode implantation under neurophysiology guidance followed by the implantation of a permanent generator after a successful trial period. We report the cases of three women who underwent this procedure as a last-resort treatment option. After 2 years of follow-up, their symptoms are still significantly improved. No major complication occurred.

A Prospective Randomized Clinical Trial of a Novel, Noninvasive Perfusion Enhancement System for the Prevention of Hospital-Acquired Sacral Pressure Injuries.

PubMed

Bharucha, Jitendra B; Seaman, Linda; Powers, Michele; Kelly, Erica; Seaman, Rodney; Forcier, Lea; McGinnis, Janice; Nodiff, Isabel; Pawlak, Brooke; Snyder, Samantha; Nodiff, Susan; Patel, Rohan; Squitieri, Rafael; Wang, Lansheng

2018-06-08

The purpose of this study was to determine the effectiveness of a novel, noninvasive perfusion enhancement system versus beds with integrated alternating pressure capabilities for the prevention of hospital-acquired sacral region (sacral, coccygeal, and ischium) pressure injuries in a high-risk, acute care patient population. A prospective randomized trial of high-risk inpatients without preexisting sacral region pressure injuries was conducted. The sample comprised 431 randomly enrolled adult patients in a 300-bed tertiary care community teaching hospital. Subjects were randomly allocated to one of 2 groups: control and experimental. Both groups received "standard-of-care" pressure injury prevention measures per hospital policy, and both were placed on alternating pressure beds during their hospital stays. In addition, patients in the experimental group used a noninvasive perfusion enhancement system placed on top of their alternating pressure beds and recovery chairs throughout their hospital stay. Fischer's exact probability test was used to compare group differences, and odds ratio (OR) were calculated for comparing pressure injury rates in the experimental and control groups. Three hundred ninety-nine patients completed the trial; 186 patients were allocated to the experimental group and 213 patients to the control group. Eleven patients in the control group versus 2 in the experimental group developed hospital-acquired sacral region pressure injuries (51.6% vs 1.07%; P = .024). Control patients were 5.04 times more likely to develop hospital-acquired sacral region pressure injuries (OR = 0.1996; 95% CI, 0.0437-0.9125). Patients using a noninvasive perfusion enhancement system developed significantly fewer hospital-acquired sacral pressure injuries than those using an alternating pressure bed without the perfusion enhancement system. These findings suggest that a perfusion enhancement system enhances the success of use of pressure redistributing beds for prevention of hospital-acquired sacral pressure injuries.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Clinical Outcomes of Pulsed Radiofrequency Neuromodulation for the Treatment of Occipital Neuralgia

PubMed Central

Oh, In Ho; Choi, Seok Keun; Lim, Young Jin

2012-01-01

Objective Occipital neuralgia is characterized by paroxysmal jabbing pain in the dermatomes of the greater or lesser occipital nerves caused by irritation of these nerves. Although several therapies have been reported, they have only temporary therapeutic effects. We report the results of pulsed radiofrequency treatment of the occipital nerve, which was used to treat occipital neuralgia. Methods Patients were diagnosed with occipital neuralgia according to the International Classification of Headache Disorders classification criteria. We performed pulsed radiofrequency neuromodulation when patients presented with clinical findings suggestive occipital neuralgia with positive diagnostic block of the occipital nerves with local anesthetics. Patients were analyzed according to age, duration of symptoms, surgical results, complications and recurrence. Pain was measured every month after the procedure using the visual analog and total pain indexes. Results From 2010, ten patients were included in the study. The mean age was 52 years (34-70 years). The mean follow-up period was 7.5 months (6-10 months). Mean Visual Analog Scale and mean total pain index scores declined by 6.1 units and 192.1 units, respectively, during the follow-up period. No complications were reported. Conclusion Pulsed radiofrequency neuromodulation of the occipital nerve is an effective treatment for occipital neuralgia. Further controlled prospective studies are necessary to evaluate the exact effects and long-term outcomes of this treatment method. PMID:22792425

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

PubMed Central

Predescu, Oana; Colizza, Melissa

2016-01-01

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed. PMID:28018130

Hyperventilation-induced nystagmus in a large series of vestibular patients.

PubMed

Califano, L; Melillo, M G; Vassallo, A; Mazzone, S

2011-02-01

The Hyperventilation Test is widely used in the "bed-side examination" of vestibular patients. It can either activate a latent nystagmus in central or peripheral vestibular diseases or it can interact with a spontaneous nystagmus, by reducing it or increasing it. Aims of this study were to determine the incidence, patterns and temporal characteristics of Hyperventilation-induced nystagmus in patients suffering from vestibular diseases, as well as its contribution to the differential diagnosis between vestibular neuritis and neuroma of the 8(th) cranial nerve, and its behaviour in some central vestibular diseases. The present study includes 1202 patients featuring, at vestibular examination, at least one sign of vestibular system disorders or patients diagnosed with a "Migraine-related vertigo" or "Chronic subjective dizziness". The overall incidence of Hyperventilation-induced nystagmus was 21.9%. It was detected more frequently in retrocochlear vestibular diseases rather than in end-organ vestibular diseases: 5.3% in Paroxysmal Positional Vertigo, 37.1% in Menière's disease, 37.6% in compensated vestibular neuritis, 77.2% in acute vestibular neuritis and 91.7% in neuroma of the 8(th) cranial nerve. In acute vestibular neuritis, three HVIN patterns were observed: Paretic pattern: temporary enhancement of the spontaneous nystagmus; Excitatory pattern: temporary inhibition of the spontaneous nystagmus; Strong excitatory pattern: temporary inversion of the spontaneous nystagmus. Excitatory patterns proved to be time-dependent in that they disappeared and were replaced by the paretic pattern over a period of maximum 18 days since the beginning of the disorder. In acoustic neuroma, Hyperventilation-induced nystagmus was frequently observed (91.7%), either in the form of an excitatory pattern (fast phases towards the affected site) or in the form of a paretic pattern (fast phases towards the healthy side). The direction of the nystagmus is only partially related to tumour size, whereas other mechanisms, such as demyelination or a break in nerve fibres, might have an important role in triggering the situation. Hyperventilation-induced nystagmus has frequently been detected in cases of demyelinating diseases and in cerebellar diseases: in multiple sclerosis, hyperventilation inhibits a central type of spontaneous nystagmus or evokes nystagmus in 75% of patients; in cerebellar diseases, hyperventilation evokes or enhances a central spontaneous nystagmus in 72.7% of patients. In conclusion the Hyperventilation Test can provide patterns of oculomotor responses that indicate a diagnostic investigation through cerebral magnetic resonance imaging enhanced by gadolinium, upon suspicion of neuroma of the 8(th) cranial nerve or of a central disease. In our opinion, however, Hyperventilation-induced nystagmus always needs to be viewed within the more general context of a complete examination of the vestibular and acoustic system.

PubMed Central

CALIFANO, L.; MELILLO, M.G.; VASSALLO, A.; MAZZONE, S.

2011-01-01

SUMMARY The Hyperventilation Test is widely used in the "bed-side examination" of vestibular patients. It can either activate a latent nystagmus in central or peripheral vestibular diseases or it can interact with a spontaneous nystagmus, by reducing it or increasing it. Aims of this study were to determine the incidence, patterns and temporal characteristics of Hyperventilation-induced nystagmus in patients suffering from vestibular diseases, as well as its contribution to the differential diagnosis between vestibular neuritis and neuroma of the 8th cranial nerve, and its behaviour in some central vestibular diseases. The present study includes 1202 patients featuring, at vestibular examination, at least one sign of vestibular system disorders or patients diagnosed with a "Migraine-related vertigo" or "Chronic subjective dizziness". The overall incidence of Hyperventilation-induced nystagmus was 21.9%. It was detected more frequently in retrocochlear vestibular diseases rather than in end-organ vestibular diseases: 5.3% in Paroxysmal Positional Vertigo, 37.1% in Menière's disease, 37.6% in compensated vestibular neuritis, 77.2% in acute vestibular neuritis and 91.7% in neuroma of the 8th cranial nerve. In acute vestibular neuritis, three HVIN patterns were observed: Paretic pattern: temporary enhancement of the spontaneous nystagmus; Excitatory pattern: temporary inhibition of the spontaneous nystagmus; Strong excitatory pattern: temporary inversion of the spontaneous nystagmus. Excitatory patterns proved to be time-dependent in that they disappeared and were replaced by the paretic pattern over a period of maximum 18 days since the beginning of the disorder. In acoustic neuroma, Hyperventilation-induced nystagmus was frequently observed (91.7%), either in the form of an excitatory pattern (fast phases towards the affected site) or in the form of a paretic pattern (fast phases towards the healthy side). The direction of the nystagmus is only partially related to tumour size, whereas other mechanisms, such as demyelination or a break in nerve fibres, might have an important role in triggering the situation. Hyperventilation-induced nystagmus has frequently been detected in cases of demyelinating diseases and in cerebellar diseases: in multiple sclerosis, hyperventilation inhibits a central type of spontaneous nystagmus or evokes nystagmus in 75% of patients; in cerebellar diseases, hyperventilation evokes or enhances a central spontaneous nystagmus in 72.7% of patients. In conclusion the Hyperventilation Test can provide patterns of oculomotor responses that indicate a diagnostic investigation through cerebral magnetic resonance imaging enhanced by gadolinium, upon suspicion of neuroma of the 8th cranial nerve or of a central disease. In our opinion, however, Hyperventilation-induced nystagmus always needs to be viewed within the more general context of a complete examination of the vestibular and acoustic system. PMID:21808459

[Clinical use of neurostimulation].

PubMed

Schmidt, R A; Tanagho, E A

1990-07-01

Our experience is broad-based and covers a number of difficult conditions that urologists deal with regularly. In patients who have been followed for several years, consistency of stimulation response has been observed. Even after use of the stimulator for several months or years, symptoms often return as soon as the stimulation ceases in cases of a malfunction or electrode movement. Neurostimulation, however, is no panacea. Patients with specific muscular dysfunction, determined urodynamically, must be carefully selected. They must also be willing to cooperate actively in their care. Test stimulation of the sacral nerves has provided invaluable insight into the neuromuscular responses mediated by the S2-4 nerves and has thus helped identify dysfunction that is specifically associated with each of these nerves. It has also helped discern differences between the integrity of pelvic muscles and the capability of the patient to use these muscles. This information allows the urologist to focus on a specific muscular dysfunction and to re-educate the patient to use the pelvic musculature properly or, failing this, to use neurostimulation via an implant to modulate the dysfunction. There must be a strong commitment on the part of the physician. No two patients are alike. Attention to patients' symptoms, the pattern of muscle dysfunction found in the pelvis, the responses to test stimulation, the urodynamic findings with and without stimulation, and the underlying anxieties of patients, which can contribute to symptoms, are all important considerations. Neurostimulation is an exciting and fascinating addition to the urologist's armamentarium. Most important, urologists are now able to test the functional integrity of the pelvic musculature and specifically identify weakness and dysfunction. Therapy can now be based on an assessment of the functional capabilities of the nervous system involved in micturition control.

Challenges for Restoration of Lower Urinary Tract Innervation in Patients with Spinal Cord Injury: A European Single-center Retrospective Study with Long-term Follow-up.

PubMed

Sievert, Karl-Dietrich; Amend, Bastian; Roser, Florian; Badke, Andreas; Toomey, Patricia; Baron, Christopher; Kaminsky, Jan; Stenzl, Arnulf; Tatagiba, Marcos

2016-05-01

Xiao and colleagues in China reported successful restoration of bladder control in patients with spinal cord injury (SCI) by establishing a somatic-autonomic reflex pathway through lumbar-to-sacral ventral root nerve rerouting. We evaluated long-term results in eight patients who underwent this procedure at a German university clinic between 2005 and 2007. The primary outcome was the occurrence of voiding upon stimulation of the skin, with normalization of bladder pressure when filling, as assessed with videourodynamics at each visit. Videourodynamic variables, urinary tract infections, and bladder/stool events recorded in a patient diary were stored in a prospective database and reviewed retrospectively. Intraoperative testing indicated successful nerve rerouting in all eight patients. Duration of follow-up was 71 mo (range: 56-86). No patient reached the primary goal of voluntary voiding with normalization of detrusor pressure at any point during follow-up. No improvements in videourodynamic or diary variables regarding bladder function were observed. In view of the lack of short (12-18 mo) and long-term (71 mo) success in our patients and others, the risks of any surgical procedure using general anesthesia, and potential for unmet expectations to wreak havoc on patient emotional well-being, we cannot recommend this procedure for patients with SCI. Although the hope was to improve long-term outcomes of spinal cord injury patients, intraspinal nerve rerouting did not improve or normalize bladder function. In view of the lack of success, we cannot recommend this procedure until proven in clinical studies. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

A large giant cell tumor of the sacrum. Advantage of an abdomino-sacral approach.

PubMed

Alla, Abubakr H; Mahadi, Seif I; Elhassan, Ahmed M; Ahmed, Mohamed E

2005-01-01

We report a case of giant cell tumor of the sacrum, presenting with sacral pain, swelling, and change of bowel habits. Rectal examination revealed a huge retrorectal mass fixed to the sacrum but not to the wall of the rectum. Abdominal ultrasonography, computed tomography CT scan, and magnetic resonance imaging MRI showed a huge pelvic mass invading the sacrum. Exploration via posterior sacral approach was not successful due to both, extensive bleeding and difficult accessibility. Re-exploration was carried out 2 days later with the patient in lithotomy position. Using abdomino-sacral approach the mass together with part of the sacrum and the whole coccyx were excised. Histopathology reported giant cell tumor of the sacrum with no evidence of mitosis. The patient was symptomless 12 months after surgery and on follow up.

A 40-year-old woman with cauda equina syndrome caused by rectothecal fistula arising from an anterior sacral meningocele.

PubMed

Bergeron, Eric; Roux, Alain; Demers, Jacques; Vanier, Laurent E; Moore, Lynne

2010-11-01

We present a rare case of a rectothecal fistula arising from an anterior sacral meningocele in a patient with Currarino syndrome. The patient was a 40-year-old woman presenting with cauda equina syndrome and ascending meningitis. The meningocele was removed using an anterior abdominal approach. A sigmoid resection was performed with rectal on-table antegrade lavage followed by closure of the rectal fistula, closure of the rectal stump, and proximal colostomy. Closure of the sacral deficit was carried out by suturing a strip of well-vascularized omentum and fibrin glue. We discuss the characteristics, management, and evolution of this unusual case. Prompt surgical management using an anterior approach, resection of the sac, closure of the sacral deficit, and fecal diversion resulted in a satisfactory outcome.

Comparison of open reduction versus minimally invasive surgical approaches on screw position in canine sacroiliac lag-screw fixation.

PubMed

Déjardin, Loïc M; Marturello, Danielle M; Guiot, Laurent P; Guillou, Reunan P; DeCamp, Charles E

2016-07-19

To compare accuracy and consistency of sacral screw placement in canine pelves treated for sacroiliac luxation with open reduction and internal fixation (ORIF) or minimally invasive osteosynthesis (MIO) techniques. Unilateral sacroiliac luxations created experimentally in canine cadavers were stabilized with an iliosacral lag screw applied via ORIF or MIO techniques (n = 10/group). Dorsoventral and craniocaudal screw angles were measured using computed tomography multiplanar reconstructions in transverse and dorsal planes, respectively. Ratios between pilot hole length and sacral width (PL/SW-R) were obtained. Data between groups were compared statistically (p <0.05). Mean screw angles (±SD) were greater in ORIF specimens in both transverse (p <0.001) and dorsal planes (p <0.004). Mean PL/SW-R was smaller (p <0.001) in the ORIF group, yet was greater than 60%. While pilot holes exited the first sacral end-plate in three of 10 ORIF specimens, the spinal canal was not violated in either group. This study demonstrates that MIO fixation of canine sacroiliac luxations provides more accurate and consistent sacral screw placement than ORIF. With proper techniques, iatrogenic neurological damage can be avoided with both techniques. The PL /SW-R, which relates to safe screw fixation, also demonstrates that screw penetration of at least 60% of the sacral width is achievable regardless of surgical approach. These findings, along with the limited dissection needed for accurate sacral screw placement, suggest that MIO of sacroiliac luxations is a valid alternative to ORIF.

What questionnaires to use when measuring quality of life in sacral tumor patients: the updated sacral tumor survey.

PubMed

van Wulfften Palthe, Olivier D R; Janssen, Stein J; Wunder, Jay S; Ferguson, Peter C; Wei, Guo; Rose, Peter S; Yaszemski, Micheal J; Sim, Franklin H; Boland, Patrick J; Healey, John H; Hornicek, Francis J; Schwab, Joseph H

2017-05-01

Patient-reported outcomes are becoming increasingly important when investigating results of patient and disease management. In sacral tumor, the symptoms of patients can vary substantially; therefore, no single questionnaire can adequately account for the full spectrum of symptoms and disability. The purpose of this study is to analyze redundancy within the current sacral tumor survey and make a recommendation for an updated version based on the results and patient and expert opinions. A survey study from a tertiary care orthopedic oncology referral center was used. The patient sample included 70 patients with sacral tumors (78% chordoma). The following 10 questionnaires included in the current sacral tumor survey were evaluated: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Item short form, PROMIS Pain Intensity short form, PROMIS Pain Interference short form, PROMIS Neuro-QOL v1.0 Lower Extremity Function short form, PROMIS v1.0 Anxiety short form, the PROMIS v1.0 Depression short form, the International Continence Society Male short form, the Modified Obstruction-Defecation Syndrome questionnaire, the PROMIS Sexual Function Profile v1.0, and the Stoma Quality of Life tool. We performed an exploratory factor analysis to calculate the possible underlying latent traits. Spearman rank correlation coefficients were used to measure to what extent the questionnaires converged. We hypothesized the existence of six domains based on current literature: mental health, physical health, pain, gastrointestinal symptoms, sexual function, and urinary incontinence. To assess content validity, we surveyed 32 patients, 9 orthopedic oncologists, 1 medical oncologist, 1 radiation oncologist, and 1 orthopedic oncology nurse practitioner with experience in treating sacral tumor patients on the relevance of the domains. Reliability as measured by Cronbach alpha ranged from 0.65 to 0.96. Coverage measured by floor and ceiling effects ranged from 0% to 52% and from 0% to 30%, respectively. Explanatory factor analysis identified three traits to which the questionnaires that were expected to measure a similar construct correlated the most: mental health, physical function, and pain. Content validity index demonstrated low disagreement among patients (range: 0.10-0.18) and high agreement among physicians (range: 0.91-1.0) on the relevance of the proposed domains. Social health was identified by 50% of the commenting patients as an important yet missing domain. The current sacral tumor survey is incomplete and time-consuming, and not all surveys are appropriate for the sacral tumor population. Our recommended survey contains less than half the questions and includes the newly recognized social health domain. Copyright © 2016 Elsevier Inc. All rights reserved.

Public Health Implications of the 1540 nm Laser on the Cornea

DTIC Science & Technology

2007-05-30

film layer. The epithelium has numerous nerve endings that make the cornea extremely sensitive to pain when an injury occurs. This pain reflex helps...used in research by using techniques and procedures that reduce distress and pain The Three R’s have lead researchers to look for alternative models...cause severe pain and render a person incapable of working. Injury to the cornea may cause temporary to permanent vision impairment depending on how

Correlation of final evoked potential amplitudes on intraoperative electromyography of the recurrent laryngeal nerve with immediate postoperative vocal fold function after thyroid and parathyroid surgery.

PubMed

Genther, Dane J; Kandil, Emad H; Noureldine, Salem I; Tufano, Ralph P

2014-02-01

Thyroid and parathyroid surgery are among the most common operations in the United States. Recurrent laryngeal nerve (RLN) injury is an infrequent but potentially detrimental complication. To correlate the final evoked potential amplitudes on intraoperative electromyography (EMG) after stimulation of the RLN with immediate postoperative vocal fold function after thyroid and parathyroid surgery. Retrospective observational study at a tertiary academic medical center. We included 674 patients (with 1000 nerves at risk) undergoing thyroid or parathyroid surgery from July 1, 2008, through June 30, 2012. Thyroid and parathyroid surgery. The association of final evoked potential amplitudes on EMG after thyroid and parathyroid surgery with vocal fold function as determined by postoperative fiberoptic laryngoscopy. Three patients experienced permanent vocal fold paresis (VFP) secondary to intraoperative RLN transection. Of the remaining 997 RLNs at risk, 22 (2.2%) in 20 patients exhibited temporary VFP on fiberoptic laryngoscopy after extubation. Eighteen patients experienced unilateral temporary VFP, and 2 experienced bilateral VFP without the need for tracheostomy or reintubation. Of the 22 RLNs, postdissection EMG amplitudes were less than 200 µV (true-positive findings) in 21 and at least 200 µV (false-negative finding) in 1. Of the 975 RLNs (97.5%) with normal function, postdissection EMG amplitudes were at least 200 µV (true-negative findings) in 967 and less than 200 µV (false-positive findings) in 8. In regard to immediate postoperative VFP, sensitivity, specificity, positive and negative predictive values, and accuracy of postdissection EMG amplitudes of less than 200 µV were 95.5%, 99.2%, 72.4%, 99.9%, and 99.1%, respectively. Intraoperative nerve monitoring of the RLN with EMG provides real-time information regarding neurophysiologic function of the RLN and can predict immediate postoperative VFP reliably when a cutoff of 200 µV is used. The high negative predictive value means that the surgeon can presume with confidence that the RLN has not been injured in the presence of a potential of at least 200 µV. This information would be useful in patients for whom bilateral thyroid surgery is being considered.

A novel three-dimensional printed guiding device for electrode implantation of sacral neuromodulation.

PubMed

Cui, Z; Wang, Z; Ye, G; Zhang, C; Wu, G; Lv, J

2018-01-01

The aim was to test the feasibility of a novel three-dimensional (3D) printed guiding device for electrode implantation of sacral neuromodulation (SNM). A 3D printed guiding device for electrode implantation was customized to patients' anatomy of the sacral region. Liquid photopolymer was selected as the printing material. The details of the device designation and prototype building are described. The guiding device was used in two patients who underwent SNM for intractable constipation. Details of the procedure and the outcomes are given. With the help of the device, the test needle for stimulation was placed in the target sacral foramen successfully at the first attempt of puncture in both patients. The time to implant a tined SNM electrode was less than 20 min and no complications were observed. At the end of the screening phase, symptoms of constipation were relieved by more than 50% in both patients and permanent stimulation was established. The customized 3D printed guiding device for implantation of SNM is a promising instrument that facilitates a precise and quick implantation of the electrode into the target sacral foramen. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

Enhancement of the bulbocavernosus reflex during intraoperative neurophysiological monitoring through the use of double train stimulation: a pilot study.

PubMed

Skinner, Stanley; Chiri, Chala A; Wroblewski, Jill; Transfeldt, Ensor E

2007-02-01

Electrophysiological bulbocavernosus reflex (BCR) testing, during surgeries in which the constituent neural components are at risk, might supplement other low sacral (S2-4) stimulation/recording techniques. However, intraoperative BCR is not always reliably implemented. We proposed to analyze BCR signals in five surgical patients monitored with the novel application of double train stimulation (DTS) to determine if the potential could be enhanced. We prospectively planned a regime of DTS BCR with a series of intertrain delays in five monitored patients at risk for low sacral neural injury. Patients were maintained with propofol, opiate infusion, and low inhalant anesthesia without muscle relaxant. Cutaneous sensory nerves of the penis (or clitoris) were stimulated using two consecutive pulse trains (DTS). Intertrain delays were 75, 100, 125, 150, 175, 200, and 250 ms. For BCR recording, uncoated paired wires were inserted into the external anal sphincter (EAS) bilaterally. For each trial, waveform amplitude, duration, and turn count measures for the first (single train) and second (double train) response were recorded. Percent increase/decrease of the second train response compared to the first train response was calculated. There was at least a 30% increase in measures of amplitude, turn count, and duration of the second train response in 22/28, 22/28, and 14/28 of the total trials respectively. There was an insufficient number of independent observations to determine statistical significance. Intraoperative BCR is currently obtained with some difficulty using pulse train stimulation. Our preliminary evidence has identified BCR waveform enhancement using DTS and suggests that the reliability of intraoperative BCR acquisition may be further improved by the addition of this technique. Our data are insufficient to define the best intertrain interval.

[Symptom analysis of 537 patients with neurogenic intrapelvic syndrome].

PubMed

Masahiro, Takano; Shunji, Ogata; Ryoichi, Nozaki; Saburo, Hisano; Yasumitsu, Saiki; Mitsuko, Fukunaga; Shota, Takano; Masafumi, Tanaka; Shinichiro, Magata; Yasushi, Nakamura; Gentaro, Sakata; Kazutaka, Yamada

2010-12-01

To characterize the symptoms of neurogenic intrapelvic syndrome and the pathogenic mechanisms. A total of 537 patients with neurogenic intrapelvic syndrome were treated in the Takano Hospital between 2001 and 2005. Clinical data were analyzed retrospectively. The mean age was 58.5 years old. There were 205 males and 332 females. There were 80 patients(14.9%) who presented with only one symptom with anorectal pain being the most common one (43.8%, 35/80). One hundred and fifty-six(29.1%) patients had two symptoms with anorectal pain and difficult evacuation being the most common combination (26.3%, 41/156). There were 144 patients (26.8%) complained of 3 symptoms and the most common combination was anorectal pain, difficult evacuation, and abdominal discomfort (30.0%, 43/144). A combination of 4 symptoms was reported in 105 patients(19.6%) with the combination of anorectal pain, incontinence, abdominal discomfort, and lumbar discomfort being the most often(65.7%, 69/105). In addition, there were 52 patients(9.7%) who had above 5 symptoms simultaneously. The frequencies of the 5 symptoms were 73.6% for anorectal pain, 27.9% for incontinence, 69.6% for difficult evacuation, 55.3% for abdominal discomfort, and 53.6% for lumbar discomfort. Symptomatology of neurogenic intrapelvic syndrome is complicated. The pathogenic mechanism may be related to concurrent dysfunction of sacral nerve and pelvic splanchnic nerve.

Improving neuromodulation technique for refractory voiding dysfunctions: two-stage implant.

PubMed

Janknegt, R A; Weil, E H; Eerdmans, P H

1997-03-01

Neuromodulation is a new technique that uses electrical stimulation of the sacral nerves for patients with refractory urinary urge/frequency or urge-incontinence, and some forms of urinary retention. The limiting factor for receiving an implant is often a failure of the percutaneous nerve evaluation (PNE) test. Present publications mention only about a 50% success score for PNE of all patients, although the micturition diaries and urodynamic parameters are similar. We wanted to investigate whether PNE results improved by using a permanent electrode as a PNE test. This would show that improvement of the PNE technique is feasible. In 10 patients where the original PNE had failed to improve the micturition diary parameters more than 50%, a permanent electrode was implanted by operation. It was connected to an external stimulator. In those cases where the patients improved according to their micturition diary by more than 50% during a period of 4 days, the external stimulator was replaced by a permanent subcutaneous neurostimulator. Eight of the 10 patients had a good to very good result (60% to 90% improvement) during the testing period and received their implant 5 to 14 days after the first stage. The good results of the two-stage implant technique we used indicate that the development of better PNE electrodes may lead to an improvement of the testing technique and better selection between nonresponders and technical failures.

[Evidence of pudendal neuropathy in Proctalgia Fugax: perineal neurophysiological assessment in 55 patients].

PubMed

Damphousse, M; Jousse, M; Verollet, D; Guinet, A; Le Breton, F; Lacroix, P; Sheik Ismael, S; Amarenco, G

2012-04-01

Proctalgia fugax (PF) is a very common condition especially in women. Causes and pathophysiological mechanisms of PF are unknown. Recently, a pudendal neuropathy was clinically suspected in women with PF. The goal of our study was to demonstrate, or not, such abnormalities by means electrophysiological testing. Fifty-five patients with PF (45 female and 10 male, mean age 50.2 years) were evaluated. EMG testing with motor unit potential analysis of pelvic floor muscles (bulbocavernosus muscle and striated external anal sphincter), study of bulbocavernosus reflex and pudendal nerve terminal motor latencies (PNTML) were performed. EMG testing was altered in two males out of 10 (20%) and 29/45 females (64%). In women, denervation was found bilateral in 25/29 (86%). Sacral latency was delayed in eight out of 29 (bilateral in five cases, unilateral in three cases) and PNTML altered in 17 cases (13 bilateral alteration, four unilateral). A significant difference (P<0.002 Chi(2) test) was demonstrated between male and female concerning pelvic floor muscles denervation. Pelvic floor muscles denervation was a common feature in women suffering from PF, due to a stretch bilateral pudendal neuropathy. Distal lesions of the pudendal nerves, principally due to a stretch perineal neuropathy, can be imagined as a factor or co-factor of PF. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Mechanoreceptor afferent activity compared with receptor field dimensions and pressure changes in feline urinary bladder.

PubMed

Downie, J W; Armour, J A

1992-11-01

The relationship between vesical mechanoreceptor field dimensions and afferent nerve activity recorded in pelvic plexus nerve filaments was examined in chloralose-anesthetized cats. Orthogonal receptor field dimensions were monitored with piezoelectric ultrasonic crystals. Reflexly generated bladder contractile activity made measurements difficult, therefore data were collected from cats subjected to actual sacral rhizotomy. Afferent activity was episodic and was initiated at different pressure and receptor field dimension thresholds. Maximum afferent activity did not correlate with maximum volume or pressure. Furthermore, activity was not linearly related to intravesical pressure, receptor field dimensions, or calculated wall tension. Pressure-length hysteresis of the receptor fields occurred. The responses of identified afferent units and their associated receptor field dimensions to brief contractions elicited by the ganglion stimulant 1,1-dimethyl-4-phenylpiperazinium iodide (2.5-20 micrograms i.a.), studied under constant volume or constant pressure conditions, are compatible with bladder mechanoreceptors behaving as tension receptors. Because activity generated by bladder mechanoreceptors did not correlate in a simple fashion with intravesical pressure or receptor field dimensions, it is concluded that such receptors are influenced by the viscoelastic properties of the bladder wall. Furthermore, as a result of the heterogeneity of the bladder wall, receptor field tension appears to offer a more precise relationship with the activity of bladder wall mechanoreceptors than does intravesical pressure.

Temporary persistence of conduction block after prolonged kilohertz frequency alternating current on rat sciatic nerve

NASA Astrophysics Data System (ADS)

Bhadra, Narendra; Foldes, Emily; Vrabec, Tina; Kilgore, Kevin; Bhadra, Niloy

2018-02-01

Objective. Application of kilohertz frequency alternating current (KHFAC) waveforms can result in nerve conduction block that is induced in less than a second. Conduction recovers within seconds when KHFAC is applied for about 5-10 min. This study investigated the effect of repeated and prolonged application of KHFAC on rat sciatic nerve with bipolar platinum electrodes. Approach. Varying durations of KHFAC at signal amplitudes for conduction block with intervals of no stimulus were studied. Nerve conduction was monitored by recording peak Gastrocnemius muscle force utilizing stimulation electrodes proximal (PS) and distal (DS) to a blocking electrode. The PS signal traveled through the block zone on the nerve, while the DS went directly to the motor end-plate junction. The PS/DS force ratio provided a measure of conduction patency of the nerve in the block zone. Main results. Conduction recovery times were found to be significantly affected by the cumulative duration of KHFAC application. Peak stimulated muscle force returned to pre-block levels immediately after cessation of KHFAC delivery when it was applied for less than about 15 min. They fell significantly but recovered to near pre-block levels for cumulative stimulus of 50  ±  20 min, for the tested On/Off times and frequencies. Conduction recovered in two phases, an initial fast one (60-80% recovery), followed by a slower phase. No permanent conduction block was seen at the end of the observation period during any experiment. Significance. This carry-over block effect may be exploited to provide continuous conduction block in peripheral nerves without continuous application of KHFAC.

Exclusion of the Sonic Hedgehog gene as responsible for Currarino syndrome and anorectal malformations with sacral hypodevelopment.

PubMed

Seri, M; Martucciello, G; Paleari, L; Bolino, A; Priolo, M; Salemi, G; Forabosco, P; Caroli, F; Cusano, R; Tocco, T; Lerone, M; Cama, A; Torre, M; Guys, J M; Romeo, G; Jasonni, V

1999-01-01

Anorectal malformations (ARMs) are common congenital anomalies that account for 1:4 digestive malformations. ARM patients show different degrees of sacral hypodevelopment while the hemisacrum is characteristic of the Currarino syndrome (CS). Cases of CS present an association of ARM, hemisacrum and presacral mass. A gene responsible for CS has recently been mapped in 7q36. Among the genes localized in this critical region, sonic hedgehog (SHH) was thought to represent a candidate gene for CS as well as for ARM with different levels of sacral hypodevelopment according to its role in the differentiation of midline mesoderm. By linkage analysis we confirmed the critical region in one large family with recurrence of CS. In addition, the screening of SHH in 7 CS and in 15 sporadic ARM patients with sacral hypodevelopment allowed us to exclude its role in the pathogenesis of these disorders.

The superior gluteal artery perforator flap for reconstruction of sacral sores

PubMed Central

Chen, Weijian; Jiang, Bo; Zhao, Jiaju; Wang, Peiji

2016-01-01

This report describes our experiences using the superior gluteal artery perforator (SGAP) flaps for reconstruction of 2 sacral sore cases. A 47-year-old female patient and a 38-year-old man with sacral sores were treated in our unit. The size of the defects were approximately 5×6 cm2 and 8×9 cm2, the defects were repaired by SGAP flaps. The size of designed was SGAP flaps varied from 7×20 to 9×16 cm2. All flaps survived and healed primary, the texture, functions, and appearance of flaps were satisfactory, and also without region dysfunction of donor and recipient sites. The SGAP flap, which has reliable blood supply, preserves the gluteus maximus muscle and could be transferred simply and safely, is an ideal and reusable method to reconstruct sacral sores with low rate of postoperative recurrence and satisfactory appearance. PMID:27652367

Retention of urine and sacral paraesthesia in anogenital herpes simplex infection.

PubMed

Edis, R H

1981-01-01

Two definite and 2 probable cases of anogenital herpes simplex and sacral radiculitis are described. Symptoms were typical and consisted of paraesthesia and neuralgic pain in the perineum and legs, urinary retention and constipation occurring within several days to a week after an anogenital herpetic eruption. However, at presentation only 1 case had an obvious history of anogenital herpes simplex. Neurological signs were not striking and consisted of a reduced appreciation of light touch and pin prick over the sacral dermatomes and in 2 cases reduced anal sphincter tone. CSF examination in 3 patients showed a lymphocytosis. Bladder catheterisation was required for up to 2 weeks in 2 patients. The paraesthesia persisted for weeks to months. It should be more widely recognised that anogenital herpes simplex, with sacral radiculitis, is probably the commonest cause of acute retention of urine in young sexually active people.

Cost of dressings for prevention of sacral pressure ulcers.

PubMed

Inoue, Kelly Cristina; Matsuda, Laura Misue

2016-01-01

to identify costs of dressings to prevent sacral pressure ulcers in an adult intensive care unit in Paraná, Brazil. secondary analysis study with 25 patients admitted between October 2013 and March 2014, using transparent polyurethane film (n=15) or hydrocolloid dressing (n=10) on the sacral region. The cost of each intervention was based on the unit amount used in each type of dressing, and its purchase price (transparent film = R$15.80, hydrocolloid dressing = R$68.00). the mean cost/patient was R$23.17 for use of transparent film and R$190.40 for use of hydrocolloid dressing. The main reason for changing the dressing was detachment. the transparent film was the most economically advantageous alternative to prevent sacral pressure ulcers in critical care patients. However, additional studies should be carried out including assessment of the effectiveness of both dressings.

Management of Sacral Tumors Requiring Spino-Pelvic Reconstruction with Different Histopathologic Diagnosis: Evaluation with Four Cases

PubMed Central

Togral, Guray; Hasturk, Askin Esen; Kekec, Fevzi; Parpucu, Murat; Gungor, Safak

2015-01-01

In this retrospective study, surgical results of four patients with sacral tumors having disparate pathologic diagnoses, who were treated with partial or total sacrectomy and lumbopelvic stabilization were abstracted. Two patients were treated with partial sacral resection and two patients were treated with total sacrectomy and spinopelvic fixation. Fixation methods included spinopelvic fixation with rods and screws in two cases, reconstruction plate in one case, and fresh frozen allografts in two cases. Fibular allografts used for reconstruction accelerated bony union and enhanced the stability in two cases. Addition of polymethyl methacrylate in the cavity in the case of a giant cell tumor had a positive stabilizing effect on fixation. As a result, we can conclude that mechanical instability after sacral resection can be stabilized securely with lumbopelvic fixation and polymethyl methacrylate application or addition of fresh frozen allografts between the rods can augment the stability of the reconstruction. PMID:26713133

Management of Sacral Tumors Requiring Spino-Pelvic Reconstruction with Different Histopathologic Diagnosis: Evaluation with Four Cases.

PubMed

Arıkan, Murat; Togral, Guray; Hasturk, Askin Esen; Kekec, Fevzi; Parpucu, Murat; Gungor, Safak

2015-12-01

In this retrospective study, surgical results of four patients with sacral tumors having disparate pathologic diagnoses, who were treated with partial or total sacrectomy and lumbopelvic stabilization were abstracted. Two patients were treated with partial sacral resection and two patients were treated with total sacrectomy and spinopelvic fixation. Fixation methods included spinopelvic fixation with rods and screws in two cases, reconstruction plate in one case, and fresh frozen allografts in two cases. Fibular allografts used for reconstruction accelerated bony union and enhanced the stability in two cases. Addition of polymethyl methacrylate in the cavity in the case of a giant cell tumor had a positive stabilizing effect on fixation. As a result, we can conclude that mechanical instability after sacral resection can be stabilized securely with lumbopelvic fixation and polymethyl methacrylate application or addition of fresh frozen allografts between the rods can augment the stability of the reconstruction.

A short-term epidemiological study of median nerve dysfunction in practicing dental hygienists.

PubMed

Conrad, J C; Conrad, K J; Osborn, J B

1992-02-01

The purpose of this study was to assess over time changes in median nerve function in a group of 20 students who entered the University of Minnesota dental hygiene program in 1986. This is a follow-up report on 16 of the 20 students who were evaluated two years postgraduation in 1990. Comparisons were made with prior evaluations of the subjects completed at graduation in 1988, and one year postgraduation in 1989. Digital vibrometry was used to evaluate median nerve sensibility threshold at each of the time periods studied. Analysis revealed that after one year of clinical practice, there was a mean sensibility threshold shift of 11.04% in the left median nerve and 8.42% in the right median nerve as measured by digital vibrometry. Results at two years postgraduation indicated that the threshold shift observed in an earlier study had been arrested. The reasons appeared to be twofold: (1) a period of work hardening with a concept of neuromuscular ligamentous tissue hypertrophy or adaptation to the rigors of dental hygiene practice, and/or (2) the practicing dental hygienist had learned to become more efficient in the provision of hygiene procedures. There were no reported symptoms of median nerve dysfunction and none of the subjects had been diagnosed as having CTS at any time during the two years since graduation. Continued evaluations will be necessary to determine whether the observations noted during the second year postgraduation evaluation indicated temporary or permanent slowing of the conditions necessary for the development of CTS.

Critical Anatomy Relative to the Sacral Suture: A Postoperative Imaging Study After Robotic Sacrocolpopexy.

PubMed

Crisp, Catrina C; Herfel, Charles V; Pauls, Rachel N; Westermann, Lauren B; Kleeman, Steven D

2016-01-01

This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging. A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging. Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%. We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.

Improvement of hand sensibility after selective temporary anaesthesia in combination with sensory re-education.

PubMed

Hassan-Zadeh, Roghiyeh; Lajevardi, Laleh; Esfahani, Ahmadreza Roofigari; Kamali, Mohammad

2009-01-01

The results of nerve repair in adults are often poor. The study aim was to investigate the effect of repeated sessions of cutaneous forearm anaesthesia of the injured limb, in combination with sensory re-education on the recovery of the tactile discrimination and perception of touch/pressure in the injured hand after median or ulnar nerve repair. A prospective, randomized, double-blind clinical trial was designed. During a 2-week period, a topical anaesthetic cream (Lidocaine-PTC, n = 6) or placebo (n = 7) was applied repeatedly (twice a week) with occlusive bandage for 1 hour on the flexor aspect of the forearm of the same side of the nerve injury and combined with sensory re-education. Assessments of sensory function were performed prior to the experiment and after the fourth application of Lidocaine-PTC/placebo. The patients were evaluated again 4 weeks after the last Lidocaine-PTC/placebo session. Touch perception measured with Semmes-Weinstein Monofilaments (SWM), improved significantly in the Lidocaine-PTC group (p = 0.005). In placebo group, no significant changes were seen. Two{-}point discrimination improved significantly only in the Lidocaine-PTC group (p = 0.005). This finding suggests that forearm deafferentation of injured limb in combination with sensory re-education can enhance sensory recovery after nerve repair.

Sacral neuromodulation in the treatment of the unstable bladder.

PubMed

Bosch, J L

1998-07-01

Sacral neuromodulation as a treatment for urge incontinence in patients with an unstable bladder is the subject of ongoing clinical studies. Although approximately 75% of the patients treated with a permanent sacral foramen electrode implant have experienced significant improvements, it is now also clear that there is an initial failure rate of about 25%. Recent studies have pointed out the importance of improved patient selection on the basis of sex differences, urodynamic parameters and psychological factors. Also, newer forms of test stimulation and permanent electrode implantation are being explored in an effort to improve on the present results.

A survey of deep tissue injury in elite female wheelchair basketball players.

PubMed

Shimizu, Yukiyo; Mutsuzaki, Hirotaka; Tachibana, Kaori; Tsunoda, Kenji; Hotta, Kazushi; Fukaya, Takashi; Ikeda, Eiji; Yamazaki, Masashi; Wadano, Yasuyoshi

2017-01-01

To investigate deep tissue injuries (DTIs) in elite female wheelchair basketball players and identify factors associated with their occurrence. Study participants were 22 female wheelchair basketball players on the Japanese national team. The sacral and bilateral ischial regions of each participant were examined using ultrasonography to detect DTIs. DTIs were found in 15 players (68.2%). DTIs were more frequent in players with a central nervous system disorder (CNSd) (85.7%) than in those with skeletal system disease (SSd) (37.5%, p = 0.020), and in players using a wheelchair in daily life (84.6%) than those using a wheelchair only for basketball (44.4%, p = 0.046). Players with pelvic instability were more likely to have DTIs (90.9% vs. 45.5%, p = 0.017). DTIs were deeper in the ischial region than the sacral region (p = 0.022). Players with CNSd had more DTIs in sacral regions (90% vs. 10%, p = 0.014). Players with DTIs had lower systolic blood pressure (sBP), red blood cell (RBC) count, and serum creatinine levels (sCr) (all p < 0.05). Ischial DTIs were deeper than sacral DTIs. Players with CNSd had more sacral DTIs than those with SSd. CNSd, wheelchair use in daily life, pelvic instability, and lower sBP, RBC, and sCr increased the risk of DTIs.

[Sacral gigantocellular tumor treated with total sacrectomy and spinal-pelvic fixation].

PubMed

Savić, Milenko

2011-09-01

Total sacrectomy with spinal-pelvic fixation is considered to be a successful approach to the radical surgical treatment of extensive sacral tumors, however, technically very demanding, thus only rarely reported in the literature. We presented a patient with sacral gigantocellular tumor managed successfully using this method but with certain standard operative techniques improvements. A 30-year old patient with a pronounced painful syndrome and sphincter disorders was confirmed to have sacral gigantocellular tumor affecting a greater part of the sacrum. Tumor resection was performed in the first act out off retroperitoneal organs (colon and blood vessels), sacroiliac joints were open by the ventral side, the L5 discus removed, the S2-S5 roots cut off. In the second act, performed three weeks later, sacrectomy was completed by the reconstruction of pelvic ring and spinal-pelvic fixation. Then, the standard technique was modified to provide additional spinal fixation. The results of the operation (duration, blood loss, postoperative deficit) were quite comparable with, and in some aspects even better than the results published in the literature. Total sacrectomy with spinal-pelvic fixation can be a therapy of choice in patients with extensive sacral tumors requaring, however, the multidisciplinary approach and a considerable experience with instrumental spinal stabilization.

What Questionnaires To Use When Measuring Quality Of Life In Sacral Tumor Patients? The Updated Sacral Tumor Survey

PubMed Central

van Wulfften Palthe, Olivier D.R.; Janssen, Stein J.; Wunder, Jay S.; Ferguson, Peter C.; Wei, Guo; Rose, Peter. S.; Yaszemski, Micheal J.; Sim, Franklin H.; Boland, Patrick J.; Healey, John H.; Hornicek, Francis J.; Schwab, Joseph H.

2017-01-01

Background context Patient reported outcomes are becoming increasingly important when investigating results of patient and disease management. In sacral tumor patients symptoms can vary substantially, therefore no single questionnaire can adequately account for the full spectrum of symptoms and disability. Purpose The purpose of this study is to analyze redundancy within the current sacral tumor survey and make a recommendation for an updated version based on the results and patient and expert opinions. Study design/setting A survey study from a tertiary care orthopaedic oncology referral center was used for this study. Patient sample The patient sample included 70 patients with sacral tumors (78% chordoma). Outcome measures The following ten questionnaires included in the current sacral tumor survey were evaluated: the Patient Reported Outcomes Measurement Information System (PROMIS) Global Item short form, PROMIS Pain Intensity short form, PROMIS Pain Interference short form, PROMIS Neuro-QOL v1.0 Lower Extremity Function short form, PROMIS v1.0 Anxiety short form, the PROMIS v1.0 Depression short form, the International Continence Society (ICS) Male short form, the Modified Obstruction-Defecation Syndrome (MODS) questionnaire, the PROMIS Sexual Function Profile v1.0, and The Stoma Quality Of Life tool. Methods We performed an exploratory factor analysis to calculate possible underlying latent traits. Spearman rank correlation coefficients were used to measure to what extent the questionnaires converged. We hypothesized the existence of six domains based on current literature: mental health, physical health, pain, gastrointestinal symptoms, sexual function, and urinary incontinence. To assess content validity, we surveyed 32 patients, nine orthopaedic oncologists, one medical oncologist, one radiation oncologist, and an orthopaedic oncology nurse practitioner with experience in treating sacral tumor patients on the relevance of the domains. Results Reliability as measured by Cronbach alpha ranged from 0.65 to 0.96. Coverage measured by floor and ceiling effects ranged from 0 to 52% and from 0 to 30%, respectively. Explanatory factor analysis identified three traits to which the questionnaires that were expected to measure a similar construct correlated the most; mental health, physical function, and pain. Content validity index demonstrated low disagreement among patients (range: 0.10 to 0.18) and high agreement among physicians (range: 0.91 to 1.0) on the relevance of the proposed domains. Social health was identified by 50% of the commenting patients as an important yet missing domain. Conclusions The current sacral tumor survey is incomplete, time consuming, and not all surveys are appropriate for the sacral tumor population. Our recommended survey contains less than half the questions and includes the newly recognized domain social health. PMID:27856381

Stab injury to the preauricular region with laceration of the external carotid artery without involvement of the facial nerve: a case report.

PubMed

Casal, Diogo; Pelliccia, Giovanni; Pais, Diogo; Carrola-Gomes, Diogo; Angélica-Almeida, Maria; Videira-Castro, José; Goyri-O'Neill, João

2017-07-29

Open injuries to the face involving the external carotid artery are uncommon. These injuries are normally associated with laceration of the facial nerve because this nerve is more superficial than the external carotid artery. Hence, external carotid artery lesions are usually associated with facial nerve dysfunction. We present an unusual case report in which the patient had an injury to this artery with no facial nerve compromise. A 25-year-old Portuguese man sustained a stab wound injury to his right preauricular region with a broken glass. Immediate profuse bleeding ensued. Provisory tamponade of the wound was achieved at the place of aggression by two off-duty doctors. He was initially transferred to a district hospital, where a large arterial bleeding was observed and a temporary compressive dressing was applied. Subsequently, the patient was transferred to a tertiary hospital. At admission in the emergency room, he presented a pulsating lesion in the right preauricular region and slight weakness in the territory of the inferior buccal branch of the facial nerve. The physical examination suggested an arterial lesion superficial to the facial nerve. However, in the operating theater, a section of the posterior and lateral flanks of the external carotid artery inside the parotid gland was identified. No lesion of the facial nerve was observed, and the external carotid artery was repaired. To better understand the anatomical rationale of this uncommon clinical case, we dissected the preauricular region of six cadavers previously injected with colored latex solutions in the vascular system. A small triangular space between the two main branches of division of the facial nerve in which the external carotid artery was not covered by the facial nerve was observed bilaterally in all cases. This clinical case illustrates that, in a preauricular wound, the external carotid artery can be injured without facial nerve damage. However, no similar description was found in the reviewed literature, which suggests that this must be a very rare occurrence. According to the dissection study performed, this is due to the existence of a triangular space between the cervicofacial and temporofacial nerve trunks in which the external carotid artery is not covered by the facial nerve or its branches.

Clinical value of intraoperative neuromonitoring of the recurrent laryngeal nerves in improving outcomes of surgery for well-differentiated thyroid cancer.

PubMed

Barczyński, Marcin; Konturek, Aleksander; Stopa, Małgorzata; Hubalewska-Dydejczyk, Alicja; Richter, Piotr; Nowak, Wojciech

2011-04-01

The recurrent laryngeal nerve (RLN) is particularly prone to injury during thyroidectomy in case of extralaryngeal bifurcation being present in approximately one-third of patients near the inferior thyroid artery or ligament of Berry. Meticulous surgical dissection in this area may be additionally facilitated by the use of intraoperative neuromonitoring (IONM) to assure safe and complete removal of thyroid tissue. The aim of the study was to verify the hypothesis that meticulous surgical technique of tissue dissection in the area of the posterior surface of the thyroid capsule and adjacent RLN may be additionally facilitated by intraoperative neuromonitoring (IONM), and may contribute to increasing the safety and radicalness of total thyroidectomy in patients with well-differentiated thyroid cancer. The outcomes of total thyroidectomy with level VI lymph node clearance for well-differentiated thyroid cancer (WDTC; pT1-3, N0-1, Mx) were retrospectively compared between 151 patients undergoing surgery with IONM (01/2005-06/2009) and 151 patients undergoing surgery without IONM (2003-2004). RLN morbidity (calculated for nerves at risk) was assessed by videolaryngoscopy or indirect laryngoscopy (mandatory before and after surgery and at 12-month follow-up). The anatomical course of the extralaryngeal segment of RLNs were analyzed in detail in each operation. Thyroid iodine uptake (131I) was measured during endogenous TSH stimulation test a week before radioiodine therapy. Among patients operated with vs. without IONM, the early RLN injury rate was 3% vs. 6.7% (p=0.02), including 2% vs. 5% (p=0.04) of temporary nerve lesions, and 1% vs. 1.7% of permanent nerve events (p=0.31), respectively. Extralaryngeal RLN bifurcation was identified in 42 (27.8%) vs. 25 (16.6%) of patients operated with vs. without IONM, respectively (p=0.001). Mean I-131 uptake following total thyroidectomy with vs. without IONM was 0.67 ± 0.39% vs. 1.59 ± 0.69% (p<0.001). 131I uptake lower than 1% was found in 106 (70.2%) vs. 38 (25.2%) patients operated with vs. without IONM, respectively (p<0.001). Most patients with WDTC who undergo total thyroidectomy have a small amount of residual thyroid tissue. The use of IONM may improve the outcomes of surgery among these patients by both increasing the completeness of total thyroidectomy and significantly reducing the prevalence of temporary RLN injury. The possible mechanism of this improvement is the aid in dissection at the level of the Berry's ligament offered by IONM which enhances the surgeon's ability to identify a branched RLN, and allows for reduction of traction injury and neuropraxia of the anterior branch of bifid nerves.

Intraoperative navigation-guided resection of anomalous transverse processes in patients with Bertolotti's syndrome

PubMed Central

Babu, Harish; Lagman, Carlito; Kim, Terrence T.; Grode, Marshall; Johnson, J. Patrick; Drazin, Doniel

2017-01-01

Background: Bertolotti's syndrome is characterized by enlargement of the transverse process at the most caudal lumbar vertebra with a pseudoarticulation between the transverse process and sacral ala. Here, we describe the use of intraoperative three-dimensional image-guided navigation in the resection of anomalous transverse processes in two patients with Bertolotti's syndrome. Case Descriptions: Two patients diagnosed with Bertolotti's syndrome who had undergone the above-mentioned procedure were identified. The patients were 17- and 38-years-old, and presented with severe, chronic low back pain that was resistant to conservative treatment. Imaging revealed lumbosacral transitional vertebrae at the level of L5-S1, which was consistent with Bertolotti's syndrome. Injections of the pseudoarticulations resulted in only temporary symptomatic relief. Thus, the patients subsequently underwent O-arm neuronavigational resection of the bony defects. Both patients experienced immediate pain resolution (documented on the postoperative notes) and remained asymptomatic 1 year later. Conclusion: Intraoperative three-dimensional imaging and navigation guidance facilitated the resection of anomalous transverse processes in two patients with Bertolotti's syndrome. Excellent outcomes were achieved in both patients. PMID:29026672

Intraoperative navigation-guided resection of anomalous transverse processes in patients with Bertolotti's syndrome.

PubMed

Babu, Harish; Lagman, Carlito; Kim, Terrence T; Grode, Marshall; Johnson, J Patrick; Drazin, Doniel

2017-01-01

Bertolotti's syndrome is characterized by enlargement of the transverse process at the most caudal lumbar vertebra with a pseudoarticulation between the transverse process and sacral ala. Here, we describe the use of intraoperative three-dimensional image-guided navigation in the resection of anomalous transverse processes in two patients with Bertolotti's syndrome. Two patients diagnosed with Bertolotti's syndrome who had undergone the above-mentioned procedure were identified. The patients were 17- and 38-years-old, and presented with severe, chronic low back pain that was resistant to conservative treatment. Imaging revealed lumbosacral transitional vertebrae at the level of L5-S1, which was consistent with Bertolotti's syndrome. Injections of the pseudoarticulations resulted in only temporary symptomatic relief. Thus, the patients subsequently underwent O-arm neuronavigational resection of the bony defects. Both patients experienced immediate pain resolution (documented on the postoperative notes) and remained asymptomatic 1 year later. Intraoperative three-dimensional imaging and navigation guidance facilitated the resection of anomalous transverse processes in two patients with Bertolotti's syndrome. Excellent outcomes were achieved in both patients.

Herpes zoster induced neuropathic bladder--a case report.

PubMed

Tsai, Hsiu-Nan; Wu, Wen-Jeng; Huang, Shu-Pin; Su, Chin-Ming; Chen, Chung-Chin; Wang, Chii-Jye; Chou, Yii-Her; Huang, Chun-Hsiung

2002-01-01

Herpes zoster infection involving the sacral dermatomes has been associated with bladder dysfunction and, although rarely, with acute urinary retention. Less than 150 cases have been reported in the literature. After reviewing our institute's chart records covering a period of time dating from 1991 to 2001, we found that three of our patients had developed acute urinary retention following herpes zoster skin lesions of the S2-4 dermatomes. Herein we report our findings. These three patients had previously been found to have normal voiding status. However, at the time of complaint urodynamic studies revealed detrusor areflexia or detrusor hyporeflexia with decreased sensation of bladder filling. After micturation recovery, repeat urodynamic studies revealed detrusor pressure and bladder sensation recovery. After one to six weeks of treatment, all three patients could void spontaneously without catheterization. We found that, when treated with antiviral medication, supportive analgesics, and temporary urinary drainage, which included urethral catheterization and suprapubic cystostomy, acute urinary retention associated with herpes zoster has a generally favorable prognosis. In other words, we found that in spite of its rarity, herpes zoster induced neuropathic bladder dysfunction is reversible when treated appropriately.

Minimally Invasive Microendoscopic Resection of the Transverse Process for Treatment of Low Back Pain with Bertolotti's Syndrome

PubMed Central

Sakai, Toshinori; Higashino, Kosaku; Goda, Yuichiro; Mineta, Kazuaki; Sairyo, Koichi

2014-01-01

Bertolotti's syndrome is characterized by anomalous enlargement of the transverse process of the most caudal lumbar segment, causing chronic and persistent low back pain or sciatica. We describe the case of a 45-year-old woman who presented with left sciatic pain and low back pain due to a recurrent lumbar disc herniation at L4-5 with Bertolotti's syndrome. Selective L5 nerve root block and local injection of lidocaine into the articulation between the transverse process and sacral ala temporarily relieved the left sciatic pain and low back pain, respectively. To confirm the effect of local injection on low back pain, we gave a second local injection, which once again relieved the low back pain. Microendoscopic resection of the pseudoarticulation region and discectomy successfully relieved all symptoms. This report illustrates the effectiveness of minimally invasive resection of the transverse process for the treatment of low back pain with Bertolotti's syndrome. PMID:25045566

Persistent cauda equina syndrome after caudal epidural injection under severe spinal stenosis: a case report

PubMed Central

Seo, Young Tak; Kong, Hyun Ho; Lee, Goo Joo; Bang, Heui Je

2017-01-01

Caudal epidural injection (CEI) is one of the most common treatments for low-back pain with sciatica. CEI rarely leads to neurologic complications. We report a case of persistent cauda equina syndrome after CEI. A 44-year-old male patient with severe L4 and L5 spinal ste-nosis underwent CEI for low-back pain and sciatica. The CEI solution consisted of bupivacaine, hyaluronidase, triamcinolone acetonide, and normal saline. He experienced motor weakness and sensory loss in both lower extremities and neurogenic bladder for more than 1 year after the procedure. His ankle dorsiflexors, big-toe extensors, and ankle plantar flexors on both sides were checked and categorized as motor-power Medical Research Council grade 0. His bilateral ankle-jerk reflection was absent. An electrophysiological study showed lumbosacral polyradiculopathy affecting both sides of the L5 and S1 nerve roots. A urodynamic study revealed hypoactive neurogenic bladder affecting both sacral roots. PMID:28652808

Management of patients with faecal incontinence

PubMed Central

Duelund-Jakobsen, Jakob; Worsoe, Jonas; Lundby, Lilli; Christensen, Peter; Krogh, Klaus

2016-01-01

Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8–8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail. PMID:26770270

Minimally Invasive Microendoscopic Resection of the Transverse Process for Treatment of Low Back Pain with Bertolotti's Syndrome.

PubMed

Takata, Yoichiro; Sakai, Toshinori; Higashino, Kosaku; Goda, Yuichiro; Mineta, Kazuaki; Sugiura, Kosuke; Sairyo, Koichi

2014-01-01

Bertolotti's syndrome is characterized by anomalous enlargement of the transverse process of the most caudal lumbar segment, causing chronic and persistent low back pain or sciatica. We describe the case of a 45-year-old woman who presented with left sciatic pain and low back pain due to a recurrent lumbar disc herniation at L4-5 with Bertolotti's syndrome. Selective L5 nerve root block and local injection of lidocaine into the articulation between the transverse process and sacral ala temporarily relieved the left sciatic pain and low back pain, respectively. To confirm the effect of local injection on low back pain, we gave a second local injection, which once again relieved the low back pain. Microendoscopic resection of the pseudoarticulation region and discectomy successfully relieved all symptoms. This report illustrates the effectiveness of minimally invasive resection of the transverse process for the treatment of low back pain with Bertolotti's syndrome.

Radiofrequency sensory ablation as a treatment for symptomatic unilateral lumbosacral junction pseudarticulation (Bertolotti's syndrome): a case report.

PubMed

Burnham, Robert

2010-06-01

Describe the clinical presentation, diagnostic evaluation, and successful treatment of a case of symptomatic unilateral lumbosacral junction pseudarticulation using a novel radiofrequency nerve ablation technique. A 56-year-old female patient who had suffered with low back and right upper buttock pain for 16 years experienced incomplete relief with L4/5 facet joint radiofrequency ablation. She was found to have an elongated right L5 transverse process that articulated with the sacral ala (Bertolotti's syndrome). Fluoroscopically guided local anesthetic/corticosteroid injection into the pseudarthrosis eliminated her residual right buttock pain for the duration of the local anesthetic only. Complete pain relief was achieved by injecting local anesthetic circumferentially around the posterior pseudarthrosis articular margin. Accordingly, bipolar radiofrequency strip thermal lesions were created at the same locations. Complete pain relief and full restoration of function was achieved for 16 months postprocedure. This case report describes a novel radiofrequency technique for treating symptomatic lumbosacral junction pseudarticulation that warrants further evaluation.

Persistent cauda equina syndrome after caudal epidural injection under severe spinal stenosis: a case report.

PubMed

Seo, Young Tak; Kong, Hyun Ho; Lee, Goo Joo; Bang, Heui Je

2017-01-01

Caudal epidural injection (CEI) is one of the most common treatments for low-back pain with sciatica. CEI rarely leads to neurologic complications. We report a case of persistent cauda equina syndrome after CEI. A 44-year-old male patient with severe L4 and L5 spinal ste-nosis underwent CEI for low-back pain and sciatica. The CEI solution consisted of bupivacaine, hyaluronidase, triamcinolone acetonide, and normal saline. He experienced motor weakness and sensory loss in both lower extremities and neurogenic bladder for more than 1 year after the procedure. His ankle dorsiflexors, big-toe extensors, and ankle plantar flexors on both sides were checked and categorized as motor-power Medical Research Council grade 0. His bilateral ankle-jerk reflection was absent. An electrophysiological study showed lumbosacral polyradiculopathy affecting both sides of the L5 and S1 nerve roots. A urodynamic study revealed hypoactive neurogenic bladder affecting both sacral roots.

Neural pathways for colorectal control, relevance to spinal cord injury and treatment: a narrative review.

PubMed

Callaghan, Brid; Furness, John B; Pustovit, Ruslan V

2018-03-01

Narrative review. The purpose is to review the organisation of the nerve pathways that control defecation and to relate this knowledge to the deficits in colorectal function after SCI. A literature review was conducted to identify salient features of defecation control pathways and the functional consequences of damage to these pathways in SCI. The control pathways for defecation have separate pontine centres under cortical control that influence defecation. The pontine centres connect, separately, with autonomic preganglionic neurons of the spinal defecation centres and somatic motor neurons of Onuf's nucleus in the sacral spinal cord. Organised propulsive motor patterns can be generated by stimulation of the spinal defecation centres. Activation of the somatic neurons contracts the external sphincter. The analysis aids in interpreting the consequences of SCI and predicts therapeutic strategies. Analysis of the bowel control circuits identifies sites at which bowel function may be modulated after SCI. Colokinetic drugs that elicit propulsive contractions of the colorectum may provide valuable augmentation of non-pharmacological bowel management procedures.

Cranial nerve monitoring during subpial dissection in temporomesial surgery.

PubMed

Ortler, Martin; Fiegele, Thomas; Walser, Gerald; Trinka, Eugen; Eisner, Wilhelm

2011-06-01

Cranial nerves (CNs) crossing between the brainstem and skull base at the level of the tentorial hiatus may be at risk in temporomesial surgery involving subpial dissection and/or tumorous growth leading to distorted anatomy. We aimed to identify the surgical steps most likely to result in CN damage in this type of surgery. Electromyographic responses obtained with standard neuromonitoring techniques and a continuous free-running EMG were graded as either contact activity or pathological spontaneous activity (PSA) during subpial resection of temporomesial structures in 16 selective amygdalohippocampectomy cases. Integrity of peripheral motor axons was tested by transpial/transarachnoidal electrical stimulation while recording compound muscle action potentials from distal muscle(s). Continuous EMG showed pathological activity in five (31.2%) patients. Nine events with PSA (slight activity, n = 8; strong temporary activity, n = 1) were recorded. The oculomotor nerve was involved three times, the trochlear nerve twice, the facial nerve once, and all monitored nerves on three occasions. Surgical maneuvers associated with PSA were the resection of deep parts of the hippocampus and parahippocampal gyrus (CN IV, twice; CN III, once), lining with or removing cotton patties from the resection cavity (III, twice; all channels, once) and indirect exertion of tension on the intact pia/arachnoid of the uncal region while mobilizing the hippocampus and parahippocampal gyrus en bloc (all channels, once; III, once). CMAPs were observed at 0.3 mA in two patients and at 0.6 mA in one patient, and without registering the exact amount of intensity in three patients. The most dangerous steps leading to cranial nerve damage during mesial temporal lobe surgery are the final stages of the intervention while the resection is being completed in the deep posterior part and the resection cavity is being lined with patties. Distant traction may act on nerves crossing the tentorial hiatus via the intact arachnoid.

Effectiveness and Value of Prophylactic 5-Layer Foam Sacral Dressings to Prevent Hospital-Acquired Pressure Injuries in Acute Care Hospitals: An Observational Cohort Study.

PubMed

Padula, William V

The purpose of this study was to examine the effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injury rates in acute care settings. Retrospective observational cohort. We reviewed records of adult patients 18 years or older who were hospitalized at least 5 days across 38 acute care hospitals of the University Health System Consortium (UHC) and had a pressure injury as identified by Patient Safety Indicator #3 (PSI-03). All facilities are located in the United States. We collected longitudinal data pertaining to prophylactic 5-layer foam sacral dressings purchased by hospital-quarter for 38 academic medical centers between 2010 and 2015. Longitudinal data on acute care, hospital-level patient outcomes (eg, admissions and PSI-03 and pressure injury rate) were queried through the UHC clinical database/resource manager from the Johns Hopkins Medicine portal. Data on volumes of dressings purchased per UHC hospital were merged with UHC data. Mixed-effects negative binomial regression was used to test the longitudinal association of prophylactic foam sacral dressings on pressure injury rates, adjusted for hospital case-mix and Medicare payments rules. Significant pressure injury rate reductions in US acute care hospitals between 2010 and 2015 were associated with the adoption of prophylactic 5-layer foam sacral dressings within a prevention protocol (-1.0 cases/quarter; P = .002) and changes to Medicare payment rules in 2014 (-1.13 cases/quarter; P = .035). Prophylactic 5-layer foam sacral dressings are an effective component of a pressure injury prevention protocol. Hospitals adopting these technologies should expect good value for use of these products.

Effectiveness and Value of Prophylactic 5-Layer Foam Sacral Dressings to Prevent Hospital-Acquired Pressure Injuries in Acute Care Hospitals

PubMed Central

2017-01-01

PURPOSE: The purpose of this study was to examine the effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injury rates in acute care settings. DESIGN: Retrospective observational cohort. SAMPLE AND SETTING: We reviewed records of adult patients 18 years or older who were hospitalized at least 5 days across 38 acute care hospitals of the University Health System Consortium (UHC) and had a pressure injury as identified by Patient Safety Indicator #3 (PSI-03). All facilities are located in the United States. METHODS: We collected longitudinal data pertaining to prophylactic 5-layer foam sacral dressings purchased by hospital-quarter for 38 academic medical centers between 2010 and 2015. Longitudinal data on acute care, hospital-level patient outcomes (eg, admissions and PSI-03 and pressure injury rate) were queried through the UHC clinical database/resource manager from the Johns Hopkins Medicine portal. Data on volumes of dressings purchased per UHC hospital were merged with UHC data. Mixed-effects negative binomial regression was used to test the longitudinal association of prophylactic foam sacral dressings on pressure injury rates, adjusted for hospital case-mix and Medicare payments rules. RESULTS: Significant pressure injury rate reductions in US acute care hospitals between 2010 and 2015 were associated with the adoption of prophylactic 5-layer foam sacral dressings within a prevention protocol (−1.0 cases/quarter; P = .002) and changes to Medicare payment rules in 2014 (−1.13 cases/quarter; P = .035). CONCLUSIONS: Prophylactic 5-layer foam sacral dressings are an effective component of a pressure injury prevention protocol. Hospitals adopting these technologies should expect good value for use of these products. PMID:28816929

Relative Importance of Hip and Sacral Pain Among Long-Term Gynecological Cancer Survivors Treated With Pelvic Radiotherapy and Their Relationships to Mean Absorbed Doses

DOE Office of Scientific and Technical Information (OSTI.GOV)

Waldenstroem, Ann-Charlotte, E-mail: ann-charlotte.waldenstrom@oncology.gu.se; Department of Oncology, Sahlgrenska University Hospital, Gothenburg; Olsson, Caroline

Purpose: To investigate the relative importance of patient-reported hip and sacral pain after pelvic radiotherapy (RT) for gynecological cancer and its relationship to the absorbed doses in these organs. Methods and Materials: We used data from a population-based study that included 650 long-term gynecological cancer survivors treated with pelvic RT in the Gothenburg and Stockholm areas in Sweden with a median follow-up of 6 years (range, 2-15) and 344 population controls. Symptoms were assessed through a study-specific postal questionnaire. We also analyzed the hip and sacral dose-volume histogram data for 358 of the survivors. Results: Of the survivors, one inmore » three reported having or having had hip pain after completing RT. Daily pain when walking was four times as common among the survivors compared to controls. Symptoms increased in frequency with a mean absorbed dose >37.5 Gy. Also, two in five survivors reported pain in the sacrum. Sacral pain also affected their walking ability and tended to increase with a mean absorbed dose >42.5 Gy. Conclusions: Long-term survivors of gynecological cancer treated with pelvic RT experience hip and sacral pain when walking. The mean absorbed dose was significantly related to hip pain and was borderline significantly related to sacral pain. Keeping the total mean absorbed hip dose below 37.5 Gy during treatment might lower the occurrence of long-lasting pain. In relation to the controls, the survivors had a lower occurrence of pain and pain-related symptoms from the hips and sacrum compared with what has previously been reported for the pubic bone.« less

Evaluation of the Diagnostic Accuracy of Conventional 2-Dimensional and 3-Dimensional Computed Tomography for Assessing Canine Sacral and Pelvic Fractures by Radiologists, Orthopedic Surgeons, and Veterinary Medical Students.

PubMed

Stieger-Vanegas, Susanne M; Senthirajah, Sri Kumar Jamie; Nemanic, Sarah; Baltzer, Wendy; Warnock, Jennifer; Hollars, Katelyn; Lee, Scott S; Bobe, Gerd

2015-08-01

To determine, using 3 groups of evaluators of varying experience reading orthopedic CT studies, if 3-dimensional computed tomography (3D-CT) provides a more accurate and time efficient method for diagnosis of canine sacral and pelvic fractures, and displacements of the sacroiliac and coxofemoral joints compared with 2-dimensional computed tomography (2D-CT). Retrospective clinical and prospective study. Dogs (n = 23): 12 dogs with traumatic pelvic fractures, 11 canine cadavers with pelvic trauma induced by a lateral impactor. All dogs had a 2D-CT exam of the pelvis and subsequent 3D-CT reconstructions from the 2D-CT images. Both 2D-CT and 3D-CT studies were anonymized and randomly presented to 2 veterinary radiologists, 2 veterinary orthopedic surgeons, and 2 veterinary medical students. Evaluators classified fractures using a confidence scale and recorded the duration of evaluation for each modality and case. 3D-CT was a more time-efficient technique for evaluation of traumatic sacral and pelvic injuries compared with 2D-CT in all evaluator groups irrespective of experience level reading orthopedic CT studies. However, for radiologists and surgeons, 2D-CT was the more accurate technique for evaluating sacral and pelvic fractures. 3D-CT improves sacral and pelvic fracture diagnosis when added to 2D-CT; however, 3D-CT has a reduced accuracy for evaluation of sacral and pelvic fractures if used without concurrent evaluation of 2D-CT images. © Copyright 2014 by The American College of Veterinary Surgeons.

Sacral stress fracture after lumbar and lumbosacral fusion. How to manage it? A proposition based on three cases and literature review.

PubMed

Scemama, C; D'astorg, H; Guigui, P

2016-04-01

Sacral fracture after lumbosacral instrumentation could be a source of prolonged pain and a late autonomy recovery in old patients. Diagnosis remains difficult and usually delayed. No clear consensus for efficient treatment of this complication has been defined. Aim of this study was to determine how to manage them. Three patients who sustained sacral fracture after instrumented lumbosacral fusion performed for degenerative disease of the spine are discussed. History, physical examinations' findings and radiographic features are presented. Pertinent literature was analyzed. All patients complained of unspecific low back and buttock pain a few weeks after index surgery. Diagnosis was done on CT-scan. We always choose revision surgery with good functional results. Sacral stress fracture has to be reminded behind unspecific buttock or low back pain. CT-scan seems to be the best radiological test to do the diagnosis. Surgical treatment is recommended when lumbar lordosis and pelvic incidence mismatched. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Effect of surgical approach on physical activity and pain control after sacral colpopexy.

PubMed

Collins, Sarah A; Tulikangas, Paul K; O'Sullivan, David M

2012-05-01

We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved. Copyright © 2012 Mosby, Inc. All rights reserved.

Effect of neurological monitoring in postoperative 5-15 days residual thyroidectomy after primary thyroid cancer surgery.

PubMed

Long, Miao-Yun; Diao, Fei-Yu; Peng, Li-Na; Tan, Lang-Ping; Zhu, Yue; Huang, Kai; Li, Hong-Hao

2018-05-16

To explore the application of intraoperative neurological monitoring in residual thyroidectomy 5-15 days after thyroid cancer operation and the influence on postoperative serum thyroglobulin (Tg), recurrent laryngeal nerve and function of parathyroid glands. Material of patients receiving thyroid surgery from January 2010 to December 2016 was retrospectively analyzed. Cases meeting with standards were enrolled for analysis and the patients were divided into neurological monitoring group and non-neurological monitoring group in line with the use of neurological monitoring during the operation. Recurrent laryngeal nerve-injured hoarseness, hypoparathyroidism and concentration of serum Tg before and after the surgery were collected and analyzed. Four-hundred and thirty-five patients met with standards, among which 227 from neurological monitoring group and 208 from non-neurological monitoring group. Temporary hoarseness rate of non-neurological monitoring group and neurological monitoring group was 8.67% and 2.2%. Permanent hoarseness rate of non-neurological monitoring group and neurological monitoring group was 1.92% and 0.44%. Temporary hypoparathyroidism rate of non-neurological monitoring group and neurological monitoring group was 18.75% and 7.48%. Permanent hypoparathyroidism rate of non-neurological monitoring group and neurological monitoring group was 1.92% and 0.88%. Average Tg concentration 1 month after the surgery in non-neurological monitoring group and neurological monitoring group was 2.82 and 1.37 ng/mL, respectively. Rate of average Tg concentration less than 1 ng/mL 1 month after the surgery in non-neurological monitoring group and neurological monitoring group was 45.06% and 67.4%. Intraoperative neurological monitoring can be adopted in residual thyroidectomy in postoperative 5-15 days after primary thyroid cancer surgery, as to reduce incidence rate of recurrent laryngeal nerve injury and hypoparathyroidism and to enhance thorough removal of thyroid tissues and cancer tissues. © 2018 John Wiley & Sons Australia, Ltd.

CyberKnife frameless single-fraction stereotactic radiosurgery for tumors of the sacrum.

PubMed

Gerszten, Peter C; Ozhasoglu, Cihat; Burton, Steven A; Welch, William C; Vogel, William J; Atkins, Barbara A; Kalnicki, Shalom

2003-08-15

The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. The experience with radiosurgery for the treatment of spinal and sacral lesions is more limited. Sacral lesions should be amenable to radiosurgical treatment similar to that used for their intracranial counterparts. The authors evaluated a single- fraction radiosurgical technique performed using the CyberKnife Real-Time Image-Guided Radiosurgery System for the treatment of the sacral lesion. The CyberKnife is a frameless radiosurgery system based on the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the intended target without the need for frame-based fixation. All sacral lesions were located and tracked for radiation delivery relative to fiducial bone markers placed percutaneously. Eighteen patients were treated with single-fraction radiosurgery. Tumor histology included one benign and 17 malignant tumors. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographically documented tumor volume with no margin. Tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 15 Gy). Tumor volume ranged from 23.6 to 187.4 ml (mean 90 ml). The volume of the cauda equina receiving greater than 8 Gy ranged from 0 to 1 ml (mean 0.1 ml). All patients underwent the procedure in an outpatient setting. No acute radiation toxicity or new neurological deficits occurred during the mean follow-up period of 6 months. Pain improved in all 13 patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging. Stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of both benign and malignant sacral lesions. The major potential benefits of radiosurgical ablation of sacral lesions are relatively short treatment time in an outpatient setting and minimal or no side effects. This new technique offers a new and important therapeutic modality for the primary treatment of a variety of sacral tumors or for lesions not amenable to open surgical techniques.

SU-E-J-125: A Novel IMRT Planning Technique to Spare Sacral Bone Marrow in Pelvic Cancer Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

McGuire, S; Bhatia, S; Sun, W

Purpose: Develop an IMRT planning technique that can preferentially spare sacral bone marrow for pelvic cancer patients. Methods: Six pelvic cancer patients (two each with anal, cervical, and rectal cancer) were enrolled in an IRB approved protocol to obtain FLT PET images at simulation, during, and post chemoradiation therapy. Initially, conventional IMRT plans were created to maintain target coverage and reduce dose to OARs such as bladder, bowel, rectum, and femoral heads. Simulation FLT PET images were used to create IMRT plans to spare bone marrow identified as regions with SUV of 2 or greater (IMRT-BMS) within the pelvic bonesmore » from top of L3 to 5mm below the greater trochanter without compromising PTV coverage or OAR sparing when compared to the initial IMRT plan. IMRT-BMS plans used 8–10 beam angles that surrounded the subject. These plans were used for treatment. Retrospectively, the same simulation FLT PET images were used to create IMRT plans that spared bone marrow located in the sacral pelvic bone region (IMRT-FAN) also without compromising PTV coverage or OAR sparing. IMRT-FAN plans used 16 beam angles every 12° anteriorly from 90° – 270°. Optimization objectives for the sacral bone marrow avoidance region were weighted to reduce ≥V10. Results: IMRT-FAN reduced dose to the sacral bone marrow for all six subjects. The average V5, V10, V20, and V30 differences from the IMRT-BMS plan were −2.2 ± 1.7%, −11.4 ± 3.6%, −17.6 ± 5.1%, and −19.1 ± 8.1% respectively. Average PTV coverage change was 0.5% ± 0.8% from the conventional IMRT plan. Conclusion: An IMRT planning technique that uses beams from the anterior and lateral directions reduced the volume of sacral bone marrow that receives ≤10Gy while maintaining PTV coverage and OAR sparing. Additionally, the volume of sacral bone marrow that received 20 or 30 Gy was also reduced.« less

Does additional cone beam computed tomography decrease the risk of inferior alveolar nerve injury in high-risk cases undergoing third molar surgery?Does CBCT decrease the risk of IAN injury?

PubMed

Korkmaz, Y T; Kayıpmaz, S; Senel, F C; Atasoy, K T; Gumrukcu, Z

2017-05-01

The objectives of this study were to evaluate the efficacy of additional cone beam computed tomography (CBCT) imaging on decreasing the risk of inferior alveolar nerve (IAN) injury during third molar removal in patients at high risk and to assess the surgical outcomes. The study sample included patients considered at high risk for IAN injury based on panoramic radiography (PAN) evaluation. The primary predictor was the type of imaging method (PAN only or with additional CBCT). The other variables were demographic and anatomical/radiographic factors. The primary outcome variable was IAN injury. The secondary outcome variables were the preoperative surgical plan and surgical results including IAN exposure and duration of surgery. The sample comprised 122 patients (139 teeth) aged 18-48 years. Postoperative temporary IAN injury was present in three (4.2%) cases in the CBCT group and 11 (16.4%) in the PAN group at 7 days after surgery. However, none of the patients had a permanent IAN injury at the 6-month follow-up. Additional CBCT imaging was not superior to PAN in reducing IAN injury after third molar surgery during long-term follow-up. Nonetheless, CBCT may decrease the prevalence of temporary IAN injury and improve the surgical outcomes in high-risk patients. Copyright © 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Traumatic aneurysms of the internal carotid artery at the base of the skull. Two cases treated surgically.

PubMed

Magnan, P E; Branchereau, A; Cannoni, M

1992-01-01

Internal carotid aneurysms at the base of the skull after blunt trauma are infrequent but their management is difficult, leading many surgeons to only attempt ligation. We report 2 cases presenting with high traumatic aneurysms, following motorcycle accidents. The 2 aneurysms underwent repair by a venous graft. The petrous portion of the carotid artery was approached and controlled by an ENT surgeon. This "infratemporal" approach was used exposing the facial nerve, combined with temporary anterior sub-luxation of the temporomaxillary joint to expose the lower part of the carotid canal which was opened up with a drill in order to control the carotid artery in the petrous canal. Both patients developed facial nerve palsies which improved within 3 months. Postoperative angiography showed patent vein grafts and the patients were doing well, without any symptoms 18 and 24 months later.

Left lower lobe atelectasis and consolidation following cardiac surgery: the effect of topical cooling on the phrenic nerve

DOE Office of Scientific and Technical Information (OSTI.GOV)

Benjamin, J.J.; Cascade, P.N.; Rubenfire, M.

1982-01-01

Retrospective and prospective analyses of chest radiographs of patients following coronary artery bypass surgery were undertaken. Left lower lobe pulmonary infiltrate and/or atelectasis developed in 13 of 40 (32.5%) patients who were operated upon without topical cooling of the heart with ice, and in 77 of 122 (63.1%) patients in one group and 34 of 40 (85.0%) patients in another group who were operated upon with topical cooling of the heart with ice. This difference was highly significant (p<0.001). Of the patients in one group in whom left lower lobe abnormality developed, 69.2% had paralysis or paresis of the leftmore » hemidiaphragm. It is evident that application of ice to the phrenic nerve can lead to temporary paralysis of the left leaf of the diaphragm, with subsequent development of left lower lobe pulmonary infiltrate and/or atelectasis.« less

Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal.

PubMed

Djedovic, Gabriel; Metzler, Julia; Morandi, Evi M; Wachter, Tanja; Kühn, Shafreena; Pierer, Gerhard; Rieger, Ulrich M

2017-12-01

Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V-Y flap. All primary sacral pressure sores of grades III-IV that were being covered with gluteal fasciocutaneous rotational or V-Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V-Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V-Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Post-stimulus potentiation of transmission in pelvic ganglia enhances sympathetic dilatation of guinea-pig uterine artery in vitro

PubMed Central

Morris, Judy L; Gibbins, Ian L; Jobling, Phillip

2005-01-01

Vasodilatation produced by stimulation of preganglionic neurones in lumbar and sacral pathways to pelvic ganglia was studied using an in vitro preparation of guinea-pig uterine artery and associated nerves in a partitioned bath allowing selective drug application to the ganglia or artery. Arterial diameter was monitored using real time video imaging. Vasodilatations produced by hypogastric nerve stimulation (HN; 300 pulses, 10 Hz) were significantly larger and longer in duration than with pelvic nerve stimulation (N = 18). Stimulation of ipsilateral lumbar splanchnic nerves or ipsilateral third lumbar ventral roots also produced prolonged vasodilatations. Blockade of ganglionic nicotinic receptors (0.1–1 mm hexamethonium) delayed the onset and sometimes reduced the peak amplitude of dilatations, but slow dilatations persisted in 16 of 18 preparations. These dilatations were not reduced further by 3 μm capsaicin applied to the artery and ganglia, or ganglionic application of 1 μm hyoscine, 30–100 μm suramin or 10 μm CNQX. Dilatations were reduced slightly by ganglionic application of NK1 and NK3 receptor antagonists (SR140333, SR142801; 1 μm), but were reduced significantly by bathing the ganglia in 0.5 mm Ca2+ and 10 mm Mg2+. Intracellular recordings of paracervical ganglion neurones revealed fast excitatory postsynaptic potentials (EPSPs) in all neurones on HN stimulation (300 pulses, 10 Hz), and slow EPSPs (3–12 mV amplitude) in 25 of 37 neurones. Post-stimulus action potential discharge associated with slow EPSPs occurred in 16 of 37 neurones (firing rate 9.4 ± 1.5 Hz). Hexamethonium (0.1–1 mm) abolished fast EPSPs. Hexamethonium and hyoscine (1 μm) did not reduce slow EPSPs and associated post-stimulus firing in identified vasodilator neurones (with VIP immunoreactivity) or non-vasodilator paracervical neurones. These results demonstrate a predominantly sympathetic origin of autonomic pathways producing pelvic vasodilatation in females. Non-cholinergic mediators of slow transmission in pelvic ganglia produce prolonged firing of postganglionic neurones and long-lasting dilatations of the uterine artery. This mechanism would facilitate maintenance of pelvic vasodilatation on stimulation of preganglionic neurones during sexual activity. PMID:15802294

Postoperative computed tomography and low-field magnetic resonance imaging findings in dogs with degenerative lumbosacral stenosis treated by dorsal laminectomy.

PubMed

Rapp, Martin; Ley, Charles J; Hansson, Kerstin; Sjöström, Lennart

2017-03-20

To describe postoperative computed tomography (CT) and magnetic resonance imaging (MRI) findings in dogs with degenerative lumbosacral stenosis (DLSS) treated by dorsal laminectomy and partial discectomy. Prospective clinical case study of dogs diagnosed with and treated for DLSS. Surgical and clinical findings were described. Computed tomography and low field MRI findings pre- and postoperatively were described and graded. Clinical, CT and MRI examinations were performed four to 18 months after surgery. Eleven of 13 dogs were clinically improved and two dogs had unchanged clinical status postoperatively despite imaging signs of neural compression. Vacuum phenomenon, spondylosis, sclerosis of the seventh lumbar (L7) and first sacral (S1) vertebrae endplates and lumbosacral intervertebral joint osteoarthritis became more frequent in postoperative CT images. Postoperative MRI showed mild disc extrusions in five cases, and in all cases contrast enhancing non-discal tissue was present. All cases showed contrast enhancement of the L7 spinal nerves both pre- and postoperatively and seven had contrast enhancement of the lumbosacral intervertebral joints and paraspinal tissue postoperatively. Articular process fractures or fissures were noted in four dogs. The study indicates that imaging signs of neural compression are common after DLSS surgery, even in dogs that have clinical improvement. Contrast enhancement of spinal nerves and soft tissues around the region of disc herniation is common both pre- and postoperatively and thus are unreliable criteria for identifying complications of the DLSS surgery.

The treatment of peripheral nerve injuries using irradiated allografts and temporary host immunosuppression (in a rat model)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Easterling, K.J.; Trumble, T.E.

1990-10-01

Irradiation of allografts prior to transplantation and host immunosuppression with cyclosporin-A were studied separately and in combination as means of lessening the rejection of transplanted peripheral nerve tissue. Lewis and Brown Norway rats were used in the animal model, as they differ at both major and minor histocompatibility loci. Sciatic nerve grafts (2.5 cm) were used and the animals were followed for 16 weeks after nerve grafting. The outcome was studied by functional measurements (sensory testing, gait analysis, joint flexion contracture, and muscle weight), as well as by measurements of biochemical and histologic parameters (hydroxyproline concentration and axon counts, respectively).more » Sensory testing was not reliable because of crossover innervation by the saphenous nerve. Evaluation by standard gait-testing techniques was found to be unsatisfactory. However, the allografted animals receiving cyclosporin-A had significantly smaller flexion contractures, compared to the allografted animals without immunosuppression (17 degrees +/- 12 degrees vs. 44 degrees +/- 13 degrees and 51 degrees +/- 13 degrees, p less than 0.005). Allografted animals receiving short-term cyclosporin-A had contractures that were not significantly different from those seen in isografted control animals (17 degrees +/- 12 degrees vs. 22 degrees +/- 15 degrees, NS). Muscle hydroxyproline concentration analysis revealed a lower hydroxyproline concentration among the allografted groups that received irradiated allografts, compared to groups receiving nonirradiated allogeneic grafts. The studies of muscle hydroxyproline concentration and muscle weight both showed substantial reinnervation, even in allografted animals without pretreatment of the grafts or immunosuppression of the recipient animal.« less

Tenth case of bilateral hemifacial spasm treated by microvascular decompression: Review of the pathophysiology

PubMed Central

da Silva Martins, Warley Carvalho; de Albuquerque, Lucas Alverne Freitas; de Carvalho, Gervásio Teles Cardoso; Dourado, Jules Carlos; Dellaretti, Marcos; de Sousa, Atos Alves

2017-01-01

Background: Bilateral hemifacial spasm (BHFS) is a rare neurological syndrome whose diagnosis depends on excluding other facial dyskinesias. We present a case of BHFS along with a literature review. Methods: A 64-year-old white, hypertense male reported involuntary left hemiface contractions in 2001 (aged 50). In 2007, right hemifacial symptoms appeared, without spasm remission during sleep. Botulinum toxin type A application produced partial temporary improvement. Left microvascular decompression (MVD) was performed in August 2013, followed by right MVD in May 2014, with excellent results. Follow-up in March 2016 showed complete cessation of spasms without medication. Results: The literature confirms nine BHFS cases bilaterally treated by MVD, a definitive surgical option with minimal complications. Regarding HFS pathophysiology, ectopic firing and ephaptic transmissions originate in the root exit zone (REZ) of the facial nerve, due to neurovascular compression (NVC), orthodromically stimulate facial muscles and antidromically stimulate the facial nerve nucleus; this hyperexcitation continuously stimulates the facial muscles. These activated muscles can trigger somatosensory afferent skin nerve impulses and neuromuscular spindles from the trigeminal nerve, which, after transiting the Gasser ganglion and trigeminal nucleus, reach the somatosensory medial posterior ventral nucleus of the contralateral thalamus as well as the somatosensory cortical area of the face. Once activated, this area can stimulate the motor and supplementary motor areas (extrapyramidal and basal ganglia system), activating the motoneurons of the facial nerve nucleus and peripherally stimulating the facial muscles. Conclusions: We believe that bilateral MVD is the best approach in cases of BHFS. PMID:29026661

Clinical practice guideline: improving voice outcomes after thyroid surgery.

PubMed

Chandrasekhar, Sujana S; Randolph, Gregory W; Seidman, Michael D; Rosenfeld, Richard M; Angelos, Peter; Barkmeier-Kraemer, Julie; Benninger, Michael S; Blumin, Joel H; Dennis, Gregory; Hanks, John; Haymart, Megan R; Kloos, Richard T; Seals, Brenda; Schreibstein, Jerry M; Thomas, Mack A; Waddington, Carolyn; Warren, Barbara; Robertson, Peter J

2013-06-01

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period. The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well. The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Congenital talipes equinovarus and congenital vertical talus secondary to sacral agenesis.

PubMed

Bray, Jonathan James Hyett; Crosswell, Sebastien; Brown, Rick

2017-05-05

Sacral agenesis is a rare congenital defect which is associated with foot deformities such as congenital talipes equinovarus (CTEV) and less commonly congenital vertical talus (CVT). We report a 3-year-old Caucasian girl who was born with right CTEV and left CVT secondary to sacral agenesis. Her right foot was managed with a Ponseti casting method at 2 weeks, followed by an Achilles tenotomy at 4 months. The left foot was initially managed with a nocturnal dorsi-flexion splint. Both feet remained resistant and received open foot surgery at 10 months producing plantigrade feet with neutral hindfeet. At 19 months, she failed to achieve developmental milestones and examinations revealed abnormal lower limb reflexes. A full body MRI was performed which identified the sacral agenesis. We advocate early MRI of the spine to screen for spinal defects when presented with resistant foot deformities, especially when bilateral. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Characterization of herpes simplex virus type 2 latency-associated transcription in human sacral ganglia and in cell culture.

PubMed

Croen, K D; Ostrove, J M; Dragovic, L; Straus, S E

1991-01-01

The ability of herpes simplex virus type 2 (HSV-2) to establish latency in and reactivate from sacral dorsal root sensory ganglia is the basis for recurrent genital herpes. The expression of HSV-2 genes in latently infected human sacral ganglia was investigated by in situ hybridization. Hybridizations with a probe from the long repeat region of HSV-2 revealed strong nuclear signals overlying neurons in sacral ganglia from five of nine individuals. The RNA detected overlaps with the transcript for infected cell protein O but in the opposite, or "anti-sense," orientation. These observations mimic those made previously with HSV-1 in human trigeminal ganglia and confirm the recent findings during latency in HSV-2-infected mice and guinea pigs. Northern hybridization of RNA from infected Vero cells showed that an HSV-2 latency-associated transcript was similar in size to the larger (1.85 kb) latency transcript of HSV-1. Thus, HSV-1 and HSV-2 latency in human sensory ganglia are similar, if not identical, in terms of their cellular localization and pattern of transcription.

Determination of lumbosacral transitional vertebrae in kidney urinary bladder x-ray films in the Saudi population

PubMed Central

Khashoggi, Khalid G.; Hafiz, Rawan M.; Bock, Yasmin M.; Kaki, Abdullah M.

2017-01-01

Objectives: To investigated the rate of occurrence of lumbosacral transitional vertebrae (LSTV), spinal variant, in kidney urinary bladder (KUB) plain radiographs in a Saudi population. Methods: Between January 2012 to January 2015, KUB plain films obtained from patients at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, were reviewed, and the presence or absence of LSTV was documented and classified as incomplete or complete. Patients who had evidence of spinal surgery that would obscure the view were excluded. Results: A total of 2078 patients underwent KUB examinations during the study period; LSTV anomalies were detected in 158 of these. Sacralization was present in 153 (96.8%) of this cohort, while lumbarization was present in 5 (3.2%). A total of 136 (86.1%) of the sacralized segments were of the incomplete type, whereas 17 (10.7%) were complete. Of the lumbarized vertebrae, 3 (1.8%) were incomplete, and 2 (1.2%) were complete. The most frequent type in men was type Ib (28.5%) for sacralized segments, and type IIb for lumbarized segments (0.6%). In women, type Ia was the most common form of sacralized segments (11.3%) and type IIb was the most common form of lumbarized segments (2.8%). Conclusion: The prevalence of LSTV in Saudi patients is 7.6%, with a higher incidence of sacralization than lumbarization. Further studies with larger sample sizes and longer follow-up time are needed to demonstrate the clinical significance thereof. PMID:28762430

Electrical stimulation and motor recovery.

PubMed

Young, Wise

2015-01-01

In recent years, several investigators have successfully regenerated axons in animal spinal cords without locomotor recovery. One explanation is that the animals were not trained to use the regenerated connections. Intensive locomotor training improves walking recovery after spinal cord injury (SCI) in people, and >90% of people with incomplete SCI recover walking with training. Although the optimal timing, duration, intensity, and type of locomotor training are still controversial, many investigators have reported beneficial effects of training on locomotor function. The mechanisms by which training improves recovery are not clear, but an attractive theory is available. In 1949, Donald Hebb proposed a famous rule that has been paraphrased as "neurons that fire together, wire together." This rule provided a theoretical basis for a widely accepted theory that homosynaptic and heterosynaptic activity facilitate synaptic formation and consolidation. In addition, the lumbar spinal cord has a locomotor center, called the central pattern generator (CPG), which can be activated nonspecifically with electrical stimulation or neurotransmitters to produce walking. The CPG is an obvious target to reconnect after SCI. Stimulating motor cortex, spinal cord, or peripheral nerves can modulate lumbar spinal cord excitability. Motor cortex stimulation causes long-term changes in spinal reflexes and synapses, increases sprouting of the corticospinal tract, and restores skilled forelimb function in rats. Long used to treat chronic pain, motor cortex stimuli modify lumbar spinal network excitability and improve lower extremity motor scores in humans. Similarly, epidural spinal cord stimulation has long been used to treat pain and spasticity. Subthreshold epidural stimulation reduces the threshold for locomotor activity. In 2011, Harkema et al. reported lumbosacral epidural stimulation restores motor control in chronic motor complete patients. Peripheral nerve or functional electrical stimulation (FES) has long been used to activate sacral nerves to treat bladder and pelvic dysfunction and to augment motor function. In theory, FES should facilitate synaptic formation and motor recovery after regenerative therapies. Upcoming clinical trials provide unique opportunities to test the theory.

[A case of medulla oblongata compression by tortuous vertebral arteries presenting with spastic quadriplegia].

PubMed

Kamada, Takashi; Tateishi, Takahisa; Yamashita, Tamayo; Nagata, Shinji; Ohyagi, Yasumasa; Kira, Jun-Ichi

2013-01-01

We report a 58-year-old man showing spastic paraparesis due to medulla oblongata compression by tortuous vertebral arteries. He noticed weakness of both legs and gait disturbance at the age of 58 years and his symptoms progressively worsened during the following several months. General physical findings were normal. Blood pressure was normal and there were no signs of arteriosclerosis. Neurological examination on admission revealed lower-limb-dominant spasticity in all four extremities, lower-limb weakness, hyperreflexia in all extremities with positive Wartenberg's, Babinski's and Chaddock's signs, mild hypesthesia and hypopallesthesia in both lower limbs, and spastic gait. Cranial nerves were all normal. Serum was negative for antibodies against human T-cell lymphotropic virus-1 antibody. Nerve conduction and needle electromyographic studies of all four limbs revealed normal findings. Cervical, thoracic and lumbo-sacral magnetic resonance imaging (MRI) findings were all normal. Brain MRI and magnetic resonance angiography demonstrated bilateral tortuous vertebral arteries compressing the medulla oblongata. Neurovascular decompression of the right vertebral artery was performed because compression of the right side was more severe than that of the left side. Post-operative MRI revealed outward translocation of the right vertebral artery and relieved compression of the medulla oblongata on the right side. The patient's symptoms and neurological findings improved gradually after the operation. Bilateral pyramidal tract signs without cranial nerve dysfunction due to compression of the medulla oblongata by tortuous vertebral arteries are extremely rare and clinically indistinguishable from hereditary spastic paraplegia (HSP). Although we did not perform a genetic test for HSP, we consider that the spastic paraparesis and mild lower-limb hypesthesia were caused by compression of the medulla oblongata by bilateral tortuous vertebral arteries based on the post-operative improvement in symptoms. Given the favorable effects of surgery, tortuous vertebral arteries should be considered in the differential diagnosis of patients presenting with progressive spastic paraparesis.

Herpes simplex virus latency-associated transcript sequence downstream of the promoter influences type-specific reactivation and viral neurotropism.

PubMed

Bertke, Andrea S; Patel, Amita; Krause, Philip R

2007-06-01

Herpes simplex virus (HSV) establishes latency in sensory nerve ganglia during acute infection and may later periodically reactivate to cause recurrent disease. HSV type 1 (HSV-1) reactivates more efficiently than HSV-2 from trigeminal ganglia while HSV-2 reactivates more efficiently than HSV-1 from lumbosacral dorsal root ganglia (DRG) to cause recurrent orofacial and genital herpes, respectively. In a previous study, a chimeric HSV-2 that expressed the latency-associated transcript (LAT) from HSV-1 reactivated similarly to wild-type HSV-1, suggesting that the LAT influences the type-specific reactivation phenotype of HSV-2. To further define the LAT region essential for type-specific reactivation, we constructed additional chimeric HSV-2 viruses by replacing the HSV-2 LAT promoter (HSV2-LAT-P1) or 2.5 kb of the HSV-2 LAT sequence (HSV2-LAT-S1) with the corresponding regions from HSV-1. HSV2-LAT-S1 was impaired for reactivation in the guinea pig genital model, while its rescuant and HSV2-LAT-P1 reactivated with a wild-type HSV-2 phenotype. Moreover, recurrences of HSV-2-LAT-S1 were frequently fatal, in contrast to the relatively mild recurrences of the other viruses. During recurrences, HSV2-LAT-S1 DNA increased more in the sacral cord compared to its rescuant or HSV-2. Thus, the LAT sequence region, not the LAT promoter region, provides essential elements for type-specific reactivation of HSV-2 and also plays a role in viral neurotropism. HSV-1 DNA, as quantified by real-time PCR, was more abundant in the lumbar spinal cord, while HSV-2 DNA was more abundant in the sacral spinal cord, which may provide insights into the mechanism for type-specific reactivation and different patterns of central nervous system infection of HSV-1 and HSV-2.

Herpes Simplex Virus Latency-Associated Transcript Sequence Downstream of the Promoter Influences Type-Specific Reactivation and Viral Neurotropism▿

PubMed Central

Bertke, Andrea S.; Patel, Amita; Krause, Philip R.

2007-01-01

Herpes simplex virus (HSV) establishes latency in sensory nerve ganglia during acute infection and may later periodically reactivate to cause recurrent disease. HSV type 1 (HSV-1) reactivates more efficiently than HSV-2 from trigeminal ganglia while HSV-2 reactivates more efficiently than HSV-1 from lumbosacral dorsal root ganglia (DRG) to cause recurrent orofacial and genital herpes, respectively. In a previous study, a chimeric HSV-2 that expressed the latency-associated transcript (LAT) from HSV-1 reactivated similarly to wild-type HSV-1, suggesting that the LAT influences the type-specific reactivation phenotype of HSV-2. To further define the LAT region essential for type-specific reactivation, we constructed additional chimeric HSV-2 viruses by replacing the HSV-2 LAT promoter (HSV2-LAT-P1) or 2.5 kb of the HSV-2 LAT sequence (HSV2-LAT-S1) with the corresponding regions from HSV-1. HSV2-LAT-S1 was impaired for reactivation in the guinea pig genital model, while its rescuant and HSV2-LAT-P1 reactivated with a wild-type HSV-2 phenotype. Moreover, recurrences of HSV-2-LAT-S1 were frequently fatal, in contrast to the relatively mild recurrences of the other viruses. During recurrences, HSV2-LAT-S1 DNA increased more in the sacral cord compared to its rescuant or HSV-2. Thus, the LAT sequence region, not the LAT promoter region, provides essential elements for type-specific reactivation of HSV-2 and also plays a role in viral neurotropism. HSV-1 DNA, as quantified by real-time PCR, was more abundant in the lumbar spinal cord, while HSV-2 DNA was more abundant in the sacral spinal cord, which may provide insights into the mechanism for type-specific reactivation and different patterns of central nervous system infection of HSV-1 and HSV-2. PMID:17409161

Giant anterior sacral meningocele presenting as bacterial meningitis in a previously healthy adult.

PubMed

Miletic, D; Poljak, I; Eskinja, N; Valkovic, P; Sestan, B; Troselj-Vukic, B

2008-02-01

Meningocele may be asymptomatic and incidentally discovered. Presenting as a retrorectal mass, sacral meningocele may produce urinary, rectal, and menstrual pain. Anterior sacral meningocele may be the cause of tethered cord syndrome. This article presents a case of a previously healthy 39-year-old man with large meningeal herniation that occupied the entire pelvis who developed symptoms of bacterial meningitis. A 39-year-old man was admitted with fever, chills, headache and photophobia. Escherichia coli was isolated from cerebrospinal fluid culture. Moderate improvement regarding meningeal symptoms was noted due to intravenous antibiotic therapy, but intense pain in the lower back associated with constipation, fecal and urinary incontinence, and saddle anesthesia developed. Abdominal ultrasound was negative. Plain radiographs and computed tomography demonstrated sacral bone defect and retrorectal expansive mass. MRI confirmed anterior sacral meningocele with cord tethering. After posterior laminectomy and dural opening, communication between meningocele and intrathecal compartment was obliterated. Computed tomography-guided percutaneous drainage through the ischiorectal fossa was performed to treat residual presacral cyst. Delayed diagnosis in our patient was related to misleading signs of bacterial meningitis without symptoms of intrapelvic expansion until the second week of illness. In our patient, surgical treatment was unavoidable due to resistive meningitis, acute back pain, and symptoms of space-occupying pelvic lesion. Neurosurgical approach was successful in treatment of meningitis and neurological disorders. Computed tomography-guided evacuation of the residual retrorectal cyst was less invasive than laparotomy, resulting in normalization of defecation and miction despite incomplete evacuation. Further follow-up studies may provide insight into the most effective treatment of such conditions.

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores.

PubMed

Chen, Yen-Chou; Huang, Eng-Yen; Lin, Pao-Yuan

2014-03-01

The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Sacral neuromodulation for the treatment of neurogenic lower urinary tract dysfunction caused by multiple sclerosis: a single-centre prospective series.

PubMed

Engeler, Daniel S; Meyer, Daniel; Abt, Dominik; Müller, Stefanie; Schmid, Hans-Peter

2015-10-23

Sacral neuromodulation is well established in the treatment of refractory, non-neurogenic lower urinary tract dysfunction, but its efficacy and safety in patients with lower urinary tract dysfunction of neurological origin is unclear. Only few case series have been reported for multiple sclerosis. We prospectively evaluated the efficacy and safety of sacral neuromodulation in patients with multiple sclerosis. Seventeen patients (13 women, 4 men) treated with sacral neuromodulation for refractory neurogenic lower urinary tract dysfunction caused by multiple sclerosis were prospectively enrolled (2007-2011). Patients had to have stable disease and confirmed neurogenic lower urinary tract dysfunction. Voiding variables, adverse events, and subjective satisfaction were assessed. Sixteen (94 %) patients had a positive test phase with a >70 % improvement. After implantation of the pulse generator (InterStim II), the improvement in voiding variables persisted. At 3 years, the median voided volume had improved significantly from 125 (range 0 to 350) to 265 ml (range 200 to 350) (p < 0.001), the post void residual from 170 (range 0 to 730) to 25 ml (range 0 to 300) (p = 0.01), micturition frequency from 12 (range 6 to 20) to 7 (range 4 to 12) (p = 0.003), and number of incontinence episodes from 3 (range 0 to 10) to 0 (range 0 to 1) (p = 0.006). The median subjective degree of satisfaction was 80 %. Only two patients developed lack of benefit. No major complications occurred. Chronic sacral neuromodulation promises to be an effective and safe treatment of refractory neurogenic lower urinary tract dysfunction in selected patients with multiple sclerosis.

Perineal colostomy prolapse: a novel application of mesh sacral pexy.

PubMed

Landen, S; Ursaru, D; Delugeau, V; Landen, C

2018-01-01

Full thickness colonic prolapse following pseudocontinent perineal colostomy has not been previously reported. Possible contributing factors include a large skin aperture at the site of the perineal stoma, the absence of anal sphincters and mesorectal attachments and the presence of a perineal hernia. A novel application of sacral pexy combined with perineal hernia repair using two prosthetic meshes is described.

Carotid endarterectomy: comparison of complications between transverse and longitudinal incision.

PubMed

Mendes, George A C; Zabramski, Joseph M; Elhadi, Ali M; Kalani, M Yashar S; Preul, Mark C; Nakaji, Peter; Spetzler, Robert F

2014-08-01

Cranial nerve injury (CNI) is the most common neurological complication associated with carotid endarterectomy (CEA). Some authors postulate that the transverse skin incision leads to increased risk of CNI. We compared the incidence of CNI associated with the transverse and longitudinal skin incisions in a high-volume cerebrovascular center. We reviewed the charts of 226 consecutive patients who underwent CEAs between January 2007 and August 2009. Pre- and postoperative standardized neurological evaluations were performed by faculty neurologists and neurosurgeons. One hundred sixty nine of 226 (75%) CEAs were performed with the use of a transverse incision. The longitudinal incision was generally reserved for patients with a high-riding carotid bifurcation. Mean patient age was 69 years (range, 45-91 years); 62% were men; 59% of patients were symptomatic and had high-grade stenosis (70%-99%). CNI occurred in 8 cases (3.5%): 5 (3%) in transverse and 3 (5.3%) with longitudinal incisions (P = .42). There were 2 marginal mandibular nerve injuries, 1 (0.6%) transverse and 1 longitudinal; 5 recurrent laryngeal nerve injuries, 4 transverse and 1 longitudinal; and 1 case of hypoglossal nerve injury associated with longitudinal incision. One hematoma was associated with CNI. All injuries were transient. Fourteen wound hematomas required surgical evacuation. The transverse skin incision for CEAs is not associated with an increased risk of CNI (P =.42). In this study, the incidence of CNI associated with the transverse incision was 3% (n = 5) vs 5% (n = 3) for longitudinal incisions. All CNIs were temporary.

[Current status of neurostimulation and neuromodulation for vesicourethral dysfunction].

PubMed

González-Chamorro, F; Verdú Tartajo, F; Hernández Fernández, C

1997-01-01

To describe the current indications, techniques and results of sacral root stimulation in patients with spinal cord lesions as a treatment for patients with high pressure bladders and/or urinary incontinence despite conservative management, as well as sacral root neuromodulation with permanent stimulators for complex bladder dysfunction: vesical instability, sensory urgency, chronic pelvic pain and chronic voiding dysfunction. The literature is reviewed, both techniques are described and the results of the most significant series are discussed, with special reference to the first groups that utilized these techniques. There is ample experience in the application of sacral root electrical stimulation. The reported results are comparable with those achieved by other treatments, such as augmentation cystoplasty. Neurostimulation and neuromodulation techniques are simple, the complications are minimal and they do not prelude the use of other therapies.

[Interest of ultrasonographic guidance in paediatric regional anaesthesia].

PubMed

Dadure, C; Raux, O; Rochette, A; Capdevila, X

2009-10-01

The use of ultrasonographic guidance for regional anaesthesia has known recently a big interest in children in recent years. The linear ultrasound probes with a 25 mm active surface area (or probes with 38 mm active surface area in older children), with high sound frequencies in the range 8-14 MHz, allow a good compromise between excellent resolution for superficial structure and good penetration depths. In children, the easiest ultrasound guided blocks are axillar blocks, femoral blocks, fascia iliaca compartment blocks, ilio-inguinal blocks and para-umbilical blocks, caudal blocks. They permit a safe and easy learning curve of these techniques. The main advantage of ultrasound guided regional anaesthesia is the visualization of different anatomical structures and the approximate localization of the tip of needle. The other advantages for ultrasound guided peripheral nerve blocks in children are: faster onset time of sensory and motor block, longer duration of sensory blockade, increase of blockade quality and reduction of local anesthetic injection. The use of ultrasonographic guidance for central block allows to visualize different structures as well as spine and his content. Spinous process, ligament flavum, dura mater, conus medullaris and cerebrospinal fluid are identifiable, and give some information on spine, epidural space and the depth between epidural space and skin. At last, in caudal block, ultrasounds permit to evaluate the anatomy of caudal epidural space, especially the relation of the sacral hiatus to the dural sac and the search of occult spinal dysraphism. Benefit of this technique is the visualization of targeted nerves or spaces and the spread of injected local anaesthetic.

A common neural element receiving rhythmic arm and leg activity as assessed by reflex modulation in arm muscles

PubMed Central

Tazoe, Toshiki; Nakajima, Tsuyoshi; Futatsubashi, Genki; Ohtsuka, Hiroyuki; Suzuki, Shinya; Zehr, E. Paul; Komiyama, Tomoyoshi

2016-01-01

Neural interactions between regulatory systems for rhythmic arm and leg movements are an intriguing issue in locomotor neuroscience. Amplitudes of early latency cutaneous reflexes (ELCRs) in stationary arm muscles are modulated during rhythmic leg or arm cycling but not during limb positioning or voluntary contraction. This suggests that interneurons mediating ELCRs to arm muscles integrate outputs from neural systems controlling rhythmic limb movements. Alternatively, outputs could be integrated at the motoneuron and/or supraspinal levels. We examined whether a separate effect on the ELCR pathways and cortico-motoneuronal excitability during arm and leg cycling is integrated by neural elements common to the lumbo-sacral and cervical spinal cord. The subjects performed bilateral leg cycling (LEG), contralateral arm cycling (ARM), and simultaneous contralateral arm and bilateral leg cycling (A&L), while ELCRs in the wrist flexor and shoulder flexor muscles were evoked by superficial radial (SR) nerve stimulation. ELCR amplitudes were facilitated by cycling tasks and were larger during A&L than during ARM and LEG. A low stimulus intensity during ARM or LEG generated a larger ELCR during A&L than the sum of ELCRs during ARM and LEG. We confirmed this nonlinear increase in single motor unit firing probability following SR nerve stimulation during A&L. Furthermore, motor-evoked potentials following transcranial magnetic and electrical stimulation did not show nonlinear potentiation during A&L. These findings suggest the existence of a common neural element of the ELCR reflex pathway that is active only during rhythmic arm and leg movement and receives convergent input from contralateral arms and legs. PMID:26961103

Axonal degeneration and regeneration in sensory roots in a genital herpes model.

PubMed

Soffer, D; Martin, J R

1989-01-01

In a mouse model of genital herpes simplex virus type 2 (HSV-2) infection, roots of the lower spinal cord were examined 5 days to 6 months after inoculation. Using immunoperoxidase methods on paraffin sections, viral antigen was found in sensory ganglia, their proximal roots and distal nerves on days 5 and 6 after infection. In Epon sections, most mice had focal sensory root abnormalities in lower thoracic, lumbar or sacral levels. At days 7 and 10, lesions showed chiefly nerve fiber degeneration, particularly of large myelinated fibers. At 2 weeks, lesions contained relatively large bundles of small unmyelinated fibers with immature axon-Schwann cell relationships. From 3 to 6 weeks, lesions again contained many more small unmyelinated fibers than normal but, in increasing proportions, axons in bundles were isolated from their neighbors by Schwann cell cytoplasm, and Schwann cells having 1:1 relationships with axons showed mesaxon or thin myelin sheath formation. At later times, the proportion of small unmyelinated axons decreased in parallel with increased numbers of small myelinated axons. By 6 months, affected roots showed a relative reduction in large myelinated fibers, increased proportions of small myelinated fibers and Schwann cell nuclei. Numbers of unmyelinated fibers were reduced relative to 3- to 6-week lesions. Axonal degeneration and regeneration appears to be the chief pathological change in sensory roots in this model. If regenerated fibers arise from latently infected neurons, then establishment of latency is not a relatively silent event, but is associated with major long-lasting, morphologically detectable effects.

A case of motor neuropathy after cryolipolysis of the arm.

PubMed

Lee, Sang Jun; Kim, Young Jin; Park, Jae Beom; Suh, Dong Hye; Kwon, Do Young; Ryu, Hwa Jung

2016-11-01

Cryolipolysis treatment is a non-invasive option for localized fat reduction without damaging the surrounding tissue. Clinical studies about cryolipolysis show various side effects, including temporary erythema, bruising, and transient numbness. But, no reports are available on motor nerve malfunction after cryolipolysis. A 24-year-old female received cryolipolysis treatment on abdomen, both arms. After 10 days, patient complained of weakness and inability to lift heavy objects. Symptoms continued for 6 months, and fully recovered without treatment. Thus, we report a case of motor neuropathy after cryolipolysis, which is a rare complication of cryolipolysis.

Antinociceptive effect of vinpocetine--a comprehensive survey.

PubMed

Csillik, Bertalan; Mihály, András; Knyihár-Csillik, Elizabeth

2010-05-30

Blockade of retrograde transport of nerve growth factor (NGF) in a peripheral sensory nerve is known to induce transganglionic degenerative atrophy (TDA) of central sensory terminals in the upper dorsal horn of the related, ipsilateral segments(s) of the spinal cord. The ensuing temporary blockade of transmission of nociceptive impulses has been utilized in the therapy of intractable pain, using transcutaneous iontophoresis of the microtubule inhibitors vincristin and vinblastin, drugs which inhibit retrograde transport of NGF. Since microtubule inhibition might inhibit (at least theoretically) mitotic processes in general, we sought to find a drug which inhibits retrograde transport of NGF without microtubule inhibition. Vinpocetine, a derivate of vincamine, which does not interfere with microtubular function, was found to inhibit retrograde axoplasmic transport of NGF in peripheral sensory nerves, similarly to vincristin and vinblastin. Blockade of NGF transport is followed by transganglionic degenerative atrophy in the segmentally related, ipsilateral superficial spinal dorsal horn, characterized by depletion of the marker enzymes of nociception, fluoride resistant acid phosphatase (FRAP) and thiamine monophosphatase (TMP) from the Rolando substance and by decrease of the pain-related neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) from lamina I-II-III. Based upon these findings, it has been suggested that vinpocetine may result in a locally restricted decrease of nociception. Herewith, the structural and behavioral effects of perineurally administered vinpocetine are discussed. Nociception, induced by intraplantar injection of formalin, was mitigated by perineural application of vinpocetine; also formalin-induced expression of c-fos in the ipsilateral, segmentally related superficial dorsal horn, was prevented by this treatment. Since vinpocetine is not a microtubule inhibitor, its mode of action is enigmatic. It is assumed that the effect of vinpocetine might be related to interaction with membrane-trafficking proteins, such as signalling endosomes and the endocytosis-mediating "pincher" protein, involved in retrograde axoplasmic transport of NGF, or to interaction with glial elements, recently reported to be involved in the modulation of pain in the spinal cord. Based on animal experiments it is assumed that the temporary, locally restricted decrease of nociception, induced by vinpocetine applied via transcutaneous iontophoresis, might open up new avenues in the clinical treatment of intractable pain.

Refractory urgency urinary incontinence treatment in women: impact of age on outcomes and complications.

PubMed

Komesu, Yuko M; Amundsen, Cindy L; Richter, Holly E; Erickson, Stephen W; Ackenbom, Mary F; Andy, Uduak U; Sung, Vivian W; Albo, Michael; Gregory, W Thomas; Paraiso, Marie Fidela; Wallace, Dennis

2018-01-01

Women with refractory urgency urinary incontinence (ie, unresponsive to behavioral and pharmacological interventions) are treated with onabotulinumtoxinA or sacral neuromodulation. The objective of the study was to compare treatment efficacy and adverse events in women <65 and ≥65 years old treated with onabotulinumtoxinA or sacral neuromodulation. This study was a planned secondary analysis of a multicenter, randomized trial that enrolled community-dwelling women with refractory urgency urinary incontinence to onabotulinumtoxinA or sacral neuromodulation treatments. The primary outcome was a change in mean daily urgency urinary incontinence episodes on a bladder diary over 6 months. Secondary outcomes included ≥75% urgency urinary incontinence episode reduction, change in symptom severity/quality of life, treatment satisfaction, and treatment-related adverse events. Both age groups experienced improvement in mean urgency urinary incontinence episodes per day following each treatment. There was no evidence that mean daily urgency urinary incontinence episode reduction differed between age groups for onabotulinumtoxinA (adjusted coefficient, -0.127, 95% confidence interval, -1.233 to 0.979; P = .821) or sacral neuromodulation (adjusted coefficient, -0.698, 95% confidence interval, -1.832 to 0.437; P = .227). Among those treated with onabotulinumtoxinA, women <65 years had 3.3-fold greater odds of ≥75% resolution than women ≥65 years (95% confidence interval, 1.56 -7.02). Women <65 years had a greater reduction in Overactive Bladder Questionnaire Short Form symptom bother scores compared with women ≥65 years by 7.49 points (95% confidence interval, -3.23 to -11.74), regardless of treatment group. There was no difference between quality of life improvement by age. Women ≥65 years had more urinary tract infections following onabotulinumtoxinA and sacral neuromodulation (odds ratio, 1.9, 95% confidence interval, 1.2-3.3). There was no evidence of age differences in sacral neuromodulation revision/removal or catheterization following onabotulinumtoxinA treatment. Younger women experienced greater absolute continence, symptom improvement, and fewer urinary tract infections; both older and younger women had beneficial urgency urinary incontinence episode reduction, similar rates of other treatment adverse events, and improved quality of life. Copyright © 2017 Elsevier Inc. All rights reserved.

Infraorbital nerve transposition to expand the endoscopic transnasal maxillectomy.

PubMed

Salzano, Giovanni; Turri-Zanoni, Mario; Karligkiotis, Apostolos; Zocchi, Jacopo; Dell'Aversana Orabona, Giovanni; Califano, Luigi; Battaglia, Paolo; Castelnuovo, Paolo

2017-02-01

The infraorbital nerve (ION) is a terminal branch of the maxillary nerve (V2) providing sensory innervation to the malar skin. It is sometimes necessary to sacrifice the ION and its branches to obtain adequate maxillary sinus exposure for radical resection of sinonasal tumors. Consequently, patients suffer temporary or permanent paresthesia, hypoestesthia, and neuralgia of the face. We describe an innovative technique used for preservation of the ION while removing the anterior, superior, and lateral walls of the maxillary sinus through a medial endoscopic transnasal maxillectomy. All patients who underwent transnasal endoscopic maxillectomy with ION transposition in our institute were retrospectively reviewed. Two patients were identified who had been treated for sinonasal cancers using this approach. No major complications were observed. Transient loss of ION function was observed with complete recovery of skin sensory perception within 6 months of surgery. One patient referred to a mild permanent anesthesia of the upper incisors. No diplopia or enophthalmos were encountered in any of the patients. The ION transposition is useful for selected cases of benign and malignant sinonasal tumors that do not infiltrate the ION itself but involve the surrounding portion of the maxillary sinus. Anatomic preservation of the ION seems to be beneficial to the postoperative quality of life of such patients. © 2016 ARS-AAOA, LLC.

[X-ray characteristics of sacroiliac joint disorders and its clinical significance].

PubMed

Shi, Ning-Ning; Shen, Guo-Quan; He, Shui-Yong; Guo, Ru-bao

2013-02-01

To study the X-ray characteristics of sacroiliac joint disorders and its clinical significance,so as to provide clinical diagnosis basis for Tuina treatment of sacroiliac joint disorder. From July 2009 to March 2011,104 patients with sacroiliac joint disorder were reviewed,including 64 males and 40 females,ranging in age from 18 to 81 years, with an average of (45.39 +/- 1.30) years. The duration of the disease ranged from 1 to 144 months,with an average of (12.64 +/- 2.19) months. One hundred and four pelvic plain films and 97 lumbar spine lateral films of the patients with sacroiliac joint disorder were taken. On the lateral X-ray of lumbar,the sacral horizontal angles (lumbosacral angle) were measured; and on the X-ray of pelvis,the vertical distance of two side iliac crest (iliac crest difference), the distance from lateral border to medial margin of two hips (hip width),the clip angle between sacral spin connection and vertical axis were measured,and then the data were analyzed. The mean difference of iliac crest was (10.34+/-0.73) mm; the mean width difference of hip'was (6.73+/-1.01) mm; and the mean difference of the iliac crest was larger than that of mean difference of hip (P<0.01). The occurrence rate of inequal width of hip was higher(P<0.01). The mean abnormal lumbosacral angle was (7.29 +/- 1.86) degrees,and the mean angle of sacral crest tilting to left or right was (3.18 +/- 0.47) degrees; the mean abnormal lumbosacral angle was larger than that of angle of sacral crest tilting to left or right (P<0.01), and the occurrence rate of sacral crest tilting to left or right was higher

Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies.

PubMed

König, M A; Jehan, S; Boszczyk, A A; Boszczyk, B M

2012-05-01

U-shaped sacral fractures usually result from axial loading of the spine with simultaneous sacral pivoting due to a horizontal fracture which leads to a highly unstable spino-pelvic dissociation. Due to the rarity of these fractures, there is lack of an agreed treatment strategy. A thorough literature search was carried out to identify current treatment concepts. The studies were analysed for mechanism of injury, diagnostic imaging, associated injuries, type of surgery, follow-up times, complications, neurological, clinical and radiological outcome. Sixty-three cases were found in 12 articles. No Class I, II or III evidence was found in the literature. The most common mechanism of injury was a fall or jump from height. Pre-operative neurological deficit was noted in 50 (94.3%) out of 53 cases (not available in 10 patients). The most used surgical options were spino-pelvic fixation with or without decompression and ilio-sacral screws. Post-operative complications occurred in 24 (38.1%) patients. Average follow-up time was 18.6 months (range 2-34 months). Full neurological recovery was noted in 20 cases, partial recovery in 14 and 9 patients had no neurological recovery (5 patients were lost in follow-up). Fracture healing was mentioned in 7 articles with only 1 case of fracture reduction loss. From the current available data, an evidence based treatment strategy regarding outcome, neurological recovery or fracture healing could not be identified. Limited access and minimal-invasive surgery focussing on sacral reduction and restoration seems to offer comparable results to large spino-pelvic constructs with fewer complications and should be considered as the method of choice. If the fracture is highly unstable and displaced, spino-pelvic fixation might offer better stability.

Three-year cost-effectiveness model for non-animal stabilized hyaluronic acid and dextranomer copolymer compared with sacral nerve stimulation after conservative therapy for the management of fecal incontinence.

PubMed

Bernstein, Mitchell A; Purdy, Christopher H; Becker, Alison; Magar, Raf

2014-06-01

Two new therapies for fecal incontinence (FI) are now available: non-animal stabilized hyaluronic acid and dextranomer copolymer (NASHA/Dx) and sacral nerve stimulation (SNS). This study aimed to determine the cost-effectiveness of NASHA/Dx compared with SNS and conservative therapy (CT) for the treatment of FI after CT failure. Decision tree models with Markov subbranches were developed to compare all direct costs and outcomes during a 3-year period from the viewpoint of the US third-party payer. Costs (in 2013 US dollars) of devices, medical and surgical care, and hospitalization were included. Outcomes included quality-adjusted life-years (QALYs) and incontinence-free days (IFDs). Both costs and outcomes were discounted at an annual rate of 3%. The incremental cost-effectiveness ratio was calculated for each outcome. One-way and probabilistic sensitivity analyses were performed to examine robustness of results and model stability. A budget impact analysis was also undertaken to estimate the potential cost and savings of NASHA/Dx for a payer with 1,000,000 covered lives. For the 3-year cost-effectiveness models, the expected cost was $9053 for CT, $14,962 for NASHA/Dx, and $33,201 for SNS. The numbers of QALYs were 1.769, 1.929, and 2.004, respectively. The numbers of IFDs were 128.8, 267.6, and 514.8, respectively. The incremental cost-effectiveness ratios per additional IFD gained were $42.60 for NASHA/Dx vs CT, $73.76 for SNS vs NASHA/Dx, and $62.55 for SNS vs CT. The incremental costs per QALY gained were $37,036 for NASHA/Dx vs CT, $244,509 for SNS vs NASHA/Dx, and $103,066 for SNS vs CT. The budget impact analysis evaluated the financial effect on the health care system of the use of NASHA/Dx and SNS. For the scenarios evaluated, when all of the patients receive NASHA/Dx, the net annual effect to the health care payer budget ranged from $571,455 to $2,857,275. When all of the patients receive SNS, the net annual effect to the health care payer budget ranged from $1,959,323 to $9,796,613. Both NASHA/Dx and SNS have produced significant improvements in FI symptoms for affected patients. NASHA/Dx is a cost-effective and more efficient use of resources for the treatment of FI when compared with SNS. The budget impact analysis suggests that although reimbursement for NASHA/Dx treatment initially adds costs to the health care system, it is significantly less expensive than SNS for patients who are candidates for either treatment. Copyright © 2014 The Authors. Published by EM Inc USA.. All rights reserved.

Transcutaneous electrical nerve stimulation in the treatment of neurological patients with urinary symptoms.

PubMed

Skeil, D; Thorpe, A C

2001-12-01

To determine whether transcutaneous electrical nerve stimulation (TENS) benefits patients with urinary symptoms caused by neurological diseases. Patients with urinary symptoms from any kind of neurological disease were prospectively recruited between October 1996 and July 1998. Before attending the first assessment patients were asked to complete a week's diary recording the frequency of micturition, incontinence episodes, and frequency of pad and clothes changing. At the first assessment the patients completed the Frimodt-Moller urinary symptom questionnaire, and quality-of-life scales including the Nottingham Health Profile and Short-Form 36. Demographic and disability data (Barthel Index and Frenchay Aphasia Screening Test) were recorded, and patients underwent a neurological examination and urodynamic studies. The placing of electrode pads on the sacral dermatomes 2.5 cm either side of and 2.5 cm above the natal cleft was demonstrated, and the patient instructed to use TENS for 90 min twice a day. The current strength applied was set to that which the patient could tolerate, at a square-wave of 20 Hz and 200-micros duration. Six weeks later the patients were further assessed, where the diary exercise, questionnaires and urodynamics were repeated. In all, 44 patients (13 men and 33 women, mean age 50.8 years) were recruited. The commonest disease was multiple sclerosis and the commonest impairments para/tetraplegia or hemiplegia. There was no change in the neurological status of the 34 patients completing the study. Irritative voiding symptoms were significantly decreased (0.68-0.61, P = 0.003) and diaries also showed significant improvements in the 24 h frequency of micturition (P = 0.01), incontinence episodes (P = 0.04) and clothes changes (P = 0.02). Urodynamics showed detrusor hyper-reflexia in most patients. The only significant changes after TENS were an increased postvoid residual volume (from a mean of 134 mL to 160 mL, P = 0.03) and an increase in the volume leaked during the urodynamic study with TENS on (from a mean of 4.7 mL to 12 mL, P = 0.003). There were no significant changes in the quality-of-life scores. Of the 34 patients completing the study, half still reported a benefit from TENS at 1 year, although some patients found it took 3-4 weeks to work. TENS applied to the sacral dermatomes of neurological patients with urinary symptoms had a minimal effect on urodynamic data but significantly improved irritative urinary symptoms, 24-h urinary frequency, incontinence and clothes changing. The lack of effect on quality-of-life measures probably reflects the lack of sensitivity in the tools used in this group of patients. We therefore recommend using TENS in this often problematical group of patients.

Quantitative scintigraphy of sacroiliac joints: effects of age, gender, and laterality

DOE Office of Scientific and Technical Information (OSTI.GOV)

Vyas, K.; Eklem, M.; Seto, H.

The effects of age, gender, and laterality on sacroiliac/sacral ratios obtained during quantitative joint imaging were assessed in 97 nonarthritic control subjects. For the entire group, the right sacroiliac-to-sacral mean ratio of 1.27 in 54 males was significantly higher than the right mean ratio of 1.18 in 53 females. In both genders the right joint ratio tended to be higher than the left in all age groups. The difference in mean ratio between the two joints was wider for males than for females. The age did not afect the joint ratio in either gender. It is concluded that the rangemore » of normal sacroiliac-to-sacral ratios are different for males and females and should be taken into account during a quantitative sacroiliac joint imaging examination.« less

Rare location of spondylitis tuberculosis;atlanto-axial, sacral and cervico-thoracic junction

NASA Astrophysics Data System (ADS)

Victorio; Nasution, M. D.; Ibrahim, S.; Dharmajaya, R.

2018-03-01

Three cases of rare location spondylitis tuberculosis are reported, each in atlantoaxial, cervico-thoracic junction,and sacral. The complaints were aweakness of motoric strength and local back pain. Patients’thoracal x-ray was normal, there was no complaint of acough, PCR forTB was early diagnostic and positive in all three cases, HIV negative, intraoperative tissue samplings were sent for histopathology examination and the results showed thespecific inflammatory process. Lesions were evaluated with computer tomography and/or MRI imaging.Preoperative TB regimens therapy were given for 2 weeks and continued for nine months. The surgical procedurewas done in all cases with excellent improvement of symptoms and motoric strength. In our institution,25 cases of total TB spondylitis were performed in 2 years, only 1 case eachwas found in atlanto-axial, cervico-thoracic and sacral.

Diffuse Large Cell Lymphoma Presenting as a Sacral Mass and Lupus Anticoagulant

PubMed Central

Ediriwickrema, Lilangi S.; Zaheer, Wajih

2011-01-01

A 67-year-old gentleman presented to Yale-New Haven Hospital (YNHH) for assessment of a supratherapeutic INR and sacral lesion. Hematologic workup revealed elevated ESR, PT, INR, PTT, and CRP, mixing studies that failed to correct, and a positive Russell Viper Venom Test (RVVT), which confirmed the presence of lupus anticoagulant (LA), a subtype of antiphospholipid syndrome (APA). Pathology of the patient’s sacral lesion revealed diffuse large B-cell lymphoma. This case provides insight into the association between APA and lymphoid neoplasm. The patient’s unique presentation is in marked contrast to other reports of APA and lymphoid malignancy, which are typically associated with elevated PTT, normal PT, minimal extranodal disease, and potential thrombotic complications. Further, treatment with Rituximab-CHOP chemotherapy led to excellent clinical response with tumor remission and normalization of PT and PTT. PMID:22180680

Diffuse large cell lymphoma presenting as a sacral mass and lupus anticoagulant.

PubMed

Ediriwickrema, Lilangi S; Zaheer, Wajih

2011-12-01

A 67-year-old gentleman presented to Yale-New Haven Hospital (YNHH) for assessment of a supratherapeutic INR and sacral lesion. Hematologic workup revealed elevated ESR, PT, INR, PTT, and CRP, mixing studies that failed to correct, and a positive Russell Viper Venom Test (RVVT), which confirmed the presence of lupus anticoagulant (LA), a subtype of antiphospholipid syndrome (APA). Pathology of the patient's sacral lesion revealed diffuse large B-cell lymphoma. This case provides insight into the association between APA and lymphoid neoplasm. The patient's unique presentation is in marked contrast to other reports of APA and lymphoid malignancy, which are typically associated with elevated PTT, normal PT, minimal extranodal disease, and potential thrombotic complications. Further, treatment with Rituximab-CHOP chemotherapy led to excellent clinical response with tumor remission and normalization of PT and PTT.

Sacral myeloradiculitis complicating genital herpes in a HIV-infected patient.

PubMed

Corral, I; Quereda, C; Navas, E; Pérez-Elias, M J; Jover, F; Moreno, S

2005-02-01

Myeloradiculitis is a rare neurological complication of herpes simplex type 2 (HSV-2) infection, frequently associated with a fatal outcome. Among patients with HIV infection, HSV-2 myeloradiculitis has occasionally been reported, always associated with advanced immunosuppression and AIDS. We report a patient with HIV infection but no history of previous opportunistic infections, who developed sacral myeloradiculitis immediately after an episode of genital herpes. Magnetic resonance imaging with gadolinium showed necrotizing myelitis in the conus medullaris and enhancement of sacral roots. CD4 lymphocyte count was 530/mm3. Other possible causes of myeloradiculitis in HIV-infected patients were appropriately excluded. Acyclovir therapy resulted in partial clinical improvement. This report shows that myeloradiculitis as a complication of genital herpes may occur in the early stages of HIV infection and may have a favourable outcome with antiviral treatment.

Trans-sacral resection of a solitary fibrous tumor in the pelvis: report of a case.

PubMed

Katsuno, Hidetoshi; Maeda, Koutarou; Hanai, Tsunekazu; Sato, Harunobu; Masumori, Koji; Koide, Yoshikazu; Matsuoka, Hiroshi; Noro, Tomohito; Takakuwa, Yasunari; Hanaoka, Ryouta

2011-11-01

Solitary fibrous tumors (SFTs) develop most commonly in the pleura, although they have occasionally been reported to arise in the pelvic cavity. We report a case of an SFT presenting as a painless nodule in the pelvis of a 56-year-old woman. Histologically, the tumor was composed of spindle-shaped cells arranged without pattern, with short and narrow fascicles and interspersed bundles of thick collagen, and numerous blood vessels with a focally hemangiopericytoma-like appearance. Immunohistochemically, the tumor cells strongly expressed vimentin, CD34, and bcl-2. The tumor was excised via a trans-sacral approach, without preoperative transcatheter embolization, and the patient remains well more than 2 years after her operation. To our knowledge, this is the first case of an SFT in the pelvis, which was excised completely via a trans-sacral approach.

[Classification and Treatment of Sacroiliac Joint Dislocation].

PubMed

Tan, Zhen; Huang, Zhong; Li, Liang; Meng, Wei-Kun; Liu, Lei; Zhang, Hui; Wang, Guang-Lin; Huang, Fu-Guo

2017-09-01

To develop a renewed classification and treatment regimen for sacroiliac joint dislocation. According to the direction of dislocation of sacroiliac joint,combined iliac,sacral fractures,and fracture morphology,sacroiliac joint dislocation was classified into 4 types. Type Ⅰ (sacroiliac anterior dislocation): main fracture fragments of posterior iliac wing dislocated in front of sacroiliac joint. Type Ⅱ (sacroiliac posterior dislocation): main fracture fragments of posterior iliac wing dislocated in posterior of sacroiliac joint. Type Ⅲ (Crescent fracturedislocation of the sacroiliac joint): upward dislocation of posterior iliac wing with oblique fracture through posterior iliac wing. Type ⅢA: a large crescent fragment and dislocation comprises no more than onethird of sacroiliac joint,which is typically inferior. Type ⅢB: intermediatesize crescent fragment and dislocation comprises between one and twothirds of joint. Type ⅢC: a small crescent fragment where dislocation comprises most,but not the entire joint. Different treatment regimens were selected for different types of fractures. Treatment for type Ⅰ sacroiliac joint dislocation: anterior iliac fossa approach pry stripping reset; sacroiliac joint fixed with sacroiliac screw through percutaneous. Treatment for type Ⅱ sacroiliac joint dislocation: posterior sacroiliac joint posterior approach; sacroiliac joint fixed with sacroiliac screw under computer guidance. Treatment for type ⅢA and ⅢB sacroiliac joint dislocation: posterior sacroiliac joint approach; sacroiliac joint fixed with reconstruction plate. Treatment for type ⅢC sacroiliac joint dislocation: sacroiliac joint closed reduction; sacroiliac joint fixed with sacroiliac screw through percutaneous. Treatment for type Ⅳ sacroiliac joint dislocation: posterior approach; sacroiliac joint fixed with spinal pelvic fixation. Results of 24 to 72 months patient follow-up (mean 34.5 months): 100% survival,100% wound healing,and 100% fracture healing. Two cases were identified as type Ⅰ sacroiliac joint dislocation,including one with coexistence of nerve injury. Patients recovered completely 12 months after surgery. Eight cases were identified as type Ⅱ sacroiliac joint dislocation; none had obvious nerve injury during treatments. Twelve cases were identified as type Ⅲ sacroiliac joint dislocation,including one with coexistence of nerve injury. Patients recovered completely 12 months after surgery. Three cases were identified as type Ⅳ sacroiliac joint dislocation with coexistence of nerve injury. Two patients fully recovered 12 months after surgery. One had partial recovery of neurological function. The classification and treatment regimen for sacroiliac joint dislocation have achieved better therapeutic effect,which is worth promoting.

Recurrent laryngeal nerve injury with incomplete loss of electromyography signal during monitored thyroidectomy-evaluation and outcome.

PubMed

Wu, Che-Wei; Hao, Min; Tian, Mengzi; Dionigi, Gianlorenzo; Tufano, Ralph P; Kim, Hoon Yub; Jung, Kwang Yoon; Liu, Xiaoli; Sun, Hui; Lu, I-Cheng; Chang, Pi-Ying; Chiang, Feng-Yu

2017-06-01

During monitored thyroidectomy, a partially or completely disrupted point of nerve conduction on the exposed recurrent laryngeal nerve (RLN) indicates true electrophysiologic nerve injury. Complete loss of signal (LOS; absolute threshold value <100 μV) at the end of operation often indicates a postoperative vocal cord (VC) palsy. However, the evaluation for the injured RLN with incomplete LOS and its functional outcome has not been well described. Three hundred twenty-three patients with 522 RLNs at risk who underwent standardized monitored thyroidectomy were enrolled. The RLN was routinely stimulated at the most proximal (R 2p signal) and distal (R 2d signal) ends of exposure after thyroid resection to determine if there was an injured point on the RLN. Pre- and postoperative VC function was routinely examined. Twenty-nine RLNs (5.6 %) were detected with an injury point. Five nerves had complete LOS and other 24 nerves had incomplete LOS where the R 2p /R 2d reduction (% of amplitude reduction compared with proximal to distal RLN stimulation) ranged from 22 to 79 %. Postoperative temporary VC palsy was noted in those five RLNs with complete LOS (final vagal signal, V 2  < 100 μV) and four RLNs with incomplete LOS (R 2p /R 2d reduction 62-79 %; V 2 181-490 μV). In the remaining 20 nerves with R 2p /R 2d reduction ≤53 % (V 2 373-1623 μV), all showed normal VC mobility. Overall, false negative results were found in two RLNs (0.4 %) featuring unchanged V 2 and R 2p /R 2d but developed VC palsy. Testing and comparing the R 2p /R 2d signal is a simple and useful procedure to evaluate RLN injury after its dissection and predict functional outcome. When the relative threshold value R 2p /R 2d reduction reaches over 60 %, surgeon should consider the possibility of postoperative VC palsy.

Pubectomy and stereotactic radiotherapy for the treatment of a non-resectable sacral osteosarcoma causing pelvic canal obstruction in a dog

PubMed Central

Randall, Victoria D.; Boston, Sarah E.; Gardner, Heather L.; Griffin, Lynn; Oblak, Michelle L.; Kubicek, Lyndsay

2016-01-01

A pubectomy was carried out to relieve obstruction of the pelvic canal in a 6-year-old dog diagnosed with sacral osteosarcoma. Two days after surgery, the dog was ambulatory with normal urination and defecation. Pubectomy is a viable option to relieve clinical signs in patients with pelvic canal obstruction due to a non-resectable tumor. PMID:27587885

Neck Injury in Advanced Military Aircraft Environments

DTIC Science & Technology

1990-02-01

injury alibhis the Fast 2 nortbs In atstlitied by type of oihcrafr. This table demonstrates a statistirally significant trend in frequency (P- S5 aud...it appears that ransitional vertebrae aic relatively coarnon and equally distributed bhtweon the thoracico-lumbal (9.0%) and the lumbo- sacral area...unilateral contact of asymmetrical lumbar sacralization which increases torque forces with consequent strain on the spine and risk of disc herniation above

Accessing 3D Location of Standing Pelvis: Relative Position of Sacral Plateau and Acetabular Cavities versus Pelvis

PubMed Central

Berthonnaud, E.; Hilmi, R.; Dimnet, J.

2012-01-01

The goal of this paper is to access to pelvis position and morphology in standing posture and to determine the relative locations of their articular surfaces. This is obtained from coupling biplanar radiography and bone modeling. The technique involves different successive steps. Punctual landmarks are first reconstructed, in space, from their projected images, identified on two orthogonal standing X-rays. Geometric models, of global pelvis and articular surfaces, are determined from punctual landmarks. The global pelvis is represented as a triangle of summits: the two femoral head centers and the sacral plateau center. The two acetabular cavities are modeled as hemispheres. The anterior sacral plateau edge is represented by an hemi-ellipsis. The modeled articular surfaces are projected on each X-ray. Their optimal location is obtained when the projected contours of their models best fit real outlines identified from landmark images. Linear and angular parameters characterizing the position of global pelvis and articular surfaces are calculated from the corresponding sets of axis. Relative positions of sacral plateau, and acetabular cavities, are then calculated. Two hundred standing pelvis, of subjects and scoliotic patients, have been studied. Examples are presented. They focus upon pelvis orientations, relative positions of articular surfaces, and pelvis asymmetries. PMID:22567279

[Sacral pressure sores and their treatment].

PubMed

Bielecki, Marek; Skowroński, Rafał; Skowroński, Jan

2006-01-01

Sacral bed sores still present a serious problem in most surgery departments. They occur mainly in elderly patients of limited mobility. The treatment of such sores extends over long periods of time and therefore involves considerable costs. The material consisted of 11 sacral pressure ulcers treated surgically. The sores occurred in 4 severely disabled patients suffering from proximal third femur fractures, 4 patients with traumatic brain injury (treated in the Intensive Care Unit), and 3 patients suffering from bed sores after spinal cord injury. In 6 patients a fasciocutaneous flap was applied to the sores and in 5 cases a pedicled musculocutaneous gluteus maximus flap. The end results were assessed using Seiler's criteria. Complications of the "seroma" type were observed in 3 patients, and in 2 marginal necrosis. In all our patients complete healing was achieved within 2-4 weeks. On analysing our experience to date in surgical treatment of bed sores we are of the opinion that even extensive sacral sores can be covered with unilateral pedicled flaps provided that they are appropriately planned. Deep sores of the 4th degree sometimes with concomitant osteomyelitis require pedicled muscle flaps or in some cases musculocutaneous flaps to improve local circulation. The preparation of the patient for reconstruction surgery is just as important as the operation itself and therefore such preparation should never be neglected.

Effect of Carbon Ion Radiotherapy for Sacral Chordoma: Results of Phase I-II and Phase II Clinical Trials

DOE Office of Scientific and Technical Information (OSTI.GOV)

Imai, Reiko, E-mail: r_imai@nirs.go.j; Kamada, Tadashi; Tsuji, Hiroshi

2010-08-01

Purpose: To summarize the results of treatment for sacral chordoma in Phase I-II and Phase II carbon ion radiotherapy trials for bone and soft-tissue sarcomas. Patients and Methods: We performed a retrospective analysis of 38 patients with medically unresectable sacral chordomas treated with the Heavy Ion Medical Accelerator in Chiba, Japan between 1996 and 2003. Of the 38 patients, 30 had not received previous treatment and 8 had locally recurrent tumor after previous resection. The applied carbon ion dose was 52.8-73.6 Gray equivalents (median, 70.4) in a total of 16 fixed fractions within 4 weeks. Results: The median patient agemore » was 66 years. The cranial tumor extension was S2 or greater in 31 patients. The median clinical target volume was 523 cm{sup 3}. The median follow-up period was 80 months. The 5-year overall survival rate was 86%, and the 5-year local control rate was 89%. After treatment, 27 of 30 patients with primary tumor remained ambulatory with or without supportive devices. Two patients experienced severe skin or soft-tissue complications requiring skin grafts. Conclusion: Carbon ion radiotherapy appears effective and safe in the treatment of patients with sacral chordoma and offers a promising alternative to surgery.« less

Effects of long-term non-traumatic noise exposure on the adult central auditory system. Hearing problems without hearing loss.

PubMed

Eggermont, Jos J

2017-09-01

It is known that hearing loss induces plastic changes in the brain, causing loudness recruitment and hyperacusis, increased spontaneous firing rates and neural synchrony, reorganizations of the cortical tonotopic maps, and tinnitus. Much less in known about the central effects of exposure to sounds that cause a temporary hearing loss, affect the ribbon synapses in the inner hair cells, and cause a loss of high-threshold auditory nerve fibers. In contrast there is a wealth of information about central effects of long-duration sound exposures at levels ≤80 dB SPL that do not even cause a temporary hearing loss. The central effects for these moderate level exposures described in this review include changes in central gain, increased spontaneous firing rates and neural synchrony, and reorganization of the cortical tonotopic map. A putative mechanism is outlined, and the effect of the acoustic environment during the recovery process is illustrated. Parallels are drawn with hearing problems in humans with long-duration exposures to occupational noise but with clinical normal hearing. Copyright © 2016 Elsevier B.V. All rights reserved.

The Non-Recurrent Laryngeal Nerve: a meta-analysis and clinical considerations

PubMed Central

Sanna, Silvia; Graves, Matthew J.; Vikse, Jens; Sanna, Beatrice; Tomaszewska, Iwona M.; Tubbs, R. Shane; Walocha, Jerzy A.; Tomaszewski, Krzysztof A.

2017-01-01

Background The Non-Recurrent Laryngeal Nerve (NRLN) is a rare embryologically-derived variant of the Recurrent Laryngeal Nerve (RLN). The presence of an NRLN significantly increases the risk of iatrogenic injury and operative complications. Our aim was to provide a comprehensive meta-analysis of the overall prevalence of the NRLN, its origin, and its association with an aberrant subclavian artery. Methods Through March 2016, a database search was performed of PubMed, CNKI, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science. The references in the included articles were also extensively searched. At least two reviewers judged eligibility and assessed and extracted articles. MetaXL was used for analysis, with all pooled prevalence rates calculated using a random effects model. Heterogeneity among the included studies was assessed using the Chi2 test and the I2 statistic. Results Fifty-three studies (33,571 right RLNs) reported data on the prevalence of a right NRLN. The pooled prevalence estimate was 0.7% (95% CI [0.6–0.9]). The NRLN was found to originate from the vagus nerve at or above the laryngotracheal junction in 58.3% and below it in 41.7%. A right NRLN was associated with an aberrant subclavian artery in 86.7% of cases. Conclusion The NRLN is a rare yet very clinically relevant structure for surgeons and is associated with increased risk of iatrogenic injury, most often leading to temporary or permanent vocal cord paralysis. A thorough understanding of the prevalence, origin, and associated pathologies is vital for preventing injuries and complications. PMID:28344898

Cervical Sympathetic Chain Schwannoma Masquerading as a Vagus Nerve Schwannoma Complicated by Postoperative Horner's Syndrome and Facial Pain: A Case Report.

PubMed

Baker, Austin T; Homewood, Tyler J; Baker, Terry R

2018-06-09

Cervical Sympathetic Chain Schwannomas (CSCS) of the carotid sheath are rare neoplasms that can be misdiagnosed on imaging. The following case documents a rare incident of a misdiagnosed CSCS with unusual outcomes of permanent Horner's syndrome and facial pain. A 36-year-old female presented with a slow-growing neck mass. CT and MRI led to a preoperative diagnosis of vagus nerve schwannoma (VNS). However, surgical treatment revealed the mass to be involved with the cervical sympathetic chain rather than the vagus nerve. The diagnosis was corrected to CSCS and the nerve was resected with the mass. The patient presented postoperatively with Horner's syndrome and severe facial pain. These symptoms persisted despite two years of medical management. Studies indicate that imaging trends used for distinction between VNS and CSCS show inconsistencies in making preoperative diagnoses. Recent literature reveals helpful criteria for improving diagnostic standards that assist with preoperative patient counseling. In addition, postoperative outcomes, such as temporary, asymptomatic Horner's syndrome are common in CSCS. The following case report exemplifies the difficulties in diagnosis and addresses the unique complications of facial pain and permanent Horner's syndrome. This case report examines postoperative outcomes and improves clinician awareness of the potential for misdiagnosis of a rare neoplasm and the recently improved diagnostic measures, providing for higher quality preoperative counseling. Future research is recommended to confirm and improve diagnostic guidelines and accuracy. Additional studies may focus on evaluating the effects of incorrect preoperative diagnosis on postoperative complication rates. Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Comparison of gluteal fasciocutaneous rotational flaps and myocutaneous flaps for the treatment of sacral sores

PubMed Central

Ip, F. K.

2005-01-01

To compare the outcomes of gluteal fasciocutaneous rotational flaps and myocutaneous flaps in the treatment of sacral sores, together with a review of surgical complications in two matched cohorts. Thirty-eight patients (18 gluteal fasciocutaneous rotational flaps and 20 myocutaneous flaps) were reviewed retrospectively at a mean follow-up of 58 weeks. The rate of healing of the sore, the sore healing time, and the incidence of surgical complications, together with rate of recurrence, were obtained by chart review. Treatment groups were matched by patient characteristics, operative time and blood loss. The rate of healing of the sore, sore healing time and complication rate were comparable in the two groups but the rate of recurrence was lower to a statistically significant extent in myocutaneous flap patients. The authors suggest that both methods are comparable, good and safe in treating sacral sores; myocutaneous flaps are more durable. PMID:16333656

Intravascular flow detection during transforaminal epidural injections: a prospective assessment.

PubMed

El Abd, Omar Hamman; Amadera, Joao Eduardo Daud; Pimentel, Daniel Camargo; Pimentel, Thais Spacov Camargo

2014-01-01

Transforaminal epidural steroid injections (TFESI) are a mainstay in the treatment of spine pain. Though this commonly performed procedure is generally felt to be safe, devastating complications following inadvertent intra-arterial injections of particulate steroid have been reported. The use of digital subtraction angiography (DSA) has been suggested as a means of detecting intra-arterial needle placements prior to medication injection. To examine the efficacy of DSA in detecting intra-arterial needle placements during TFESI. Prospective cohort study evaluating the impact of DSA on detecting intra-arterial needle placements during TFESI. We enrolled 150 consecutive patients presenting to a university-affiliated spine center with discogenic and/or radicular symptoms affecting the cervical, lumbar, and sacral regions. For each injection, prior to imaging with DSA, traditional methods for vascular penetration detection were employed, including the identification of blood in the needle hub (flash), negative aspiration of blood prior to injection, and live fluoroscopic injection of contrast. Once these tests were performed and negative for signs of intra-arterial needle placement, DSA imaging was utilized prior to medication administration for identification of vascular flow. A total number of 222 TFESI were performed, 41 injections at the cervical levels (18.47%), 113 at the lumbar levels (50.9%), and 68 at the sacral levels (30.36%). Flash was observed in 13 injections performed (5.85% of the total number of injections): one (0.45%) in the cervical, 2 (0.9%) in the lumbar, and 10 (4.5%) in the sacral levels. In 11 TFESI blood aspiration was obtained (4.95% of all injections): 3 (1.3%) in cervical, 4 (1.8%) in lumbar, and 4 (1.8%) in sacral injections. Live fluoroscopy during contrast injection detected 46 (20.72%) intravascular flow patterns: 7 (3.1%) cervical, 17 (7.6%) lumbar, and 22 (9.9%) sacral. DSA identified an additional 5 intravascular injections after all previous steps had resulted in negative vascular penetration signs, which accounted for 2.25% of all injections. This is a prospective, single-center study with a relatively small number of patients and no control group. DSA detected additional 5.26% intravascular needle placements following traditional methods. Our findings also support other studies that conclude TFESI are generally a safe procedure. We recommend that special attention should be paid to the sacral injections as vascular penetration was statistically higher than at other levels.

Comparison and correlation of pelvic parameters between low-grade and high-grade spondylolisthesis.

PubMed

Min, Woo-Kie; Lee, Chang-Hwa

2014-05-01

This study was retrospectively conducted on 51 patients with L5-S1 spondylolisthesis. This study was conducted to compare a total of 11 pelvic parameters, such as the level of displacement by Meyerding method, lumbar lordosis, sacral inclination, lumbosacral angle, slip angle, S2 inclination, pelvic incidence (PI), L5 inclination, L5 slope, pelvic tilt (PT), and sacral slope (SS) between low-grade and high-grade spondylolisthesis, and to investigate a correlation of the level of displacement by Meyerding method with other pelvic parameters. Pelvic parameters were measured using preoperational erect lateral spinal simple radiographs. The patients were divided into 39 patients with low-grade spondylolisthesis and 12 patients with high-grade spondylolisthesis before analysis. In all patients of both groups, 11 radiographic measurements including the level of displacement by Meyerding method, lumbar lordosis, sacral inclination, lumbosacral angle, slip angle, S2 inclination, PI, L5 inclination, L5 slope, PT, and SS were performed. T test and Pearson correlation analysis were conducted to compare and analyze each measurement. As for the comparison between the 2 groups, a statistically great significance in the level of displacement by Meyerding method, lumbosacral angle, slip angle, L5 incidence, PI, and L5 slope (P≤0.001) was shown. Meanwhile, a statistical significance in the sacral inclination and PT (P<0.05) was also shown. However, no statistical significance in the S2 incidence and SS was shown. A correlation of the level of displacement by Meyerding method with each parameter was analyzed in the both the groups. A high correlation was observed in the lumbar lordosis, lumbosacral angle, slip angle, L5 incidence, and L5 slope (Pearson correlation coefficient, P=0.01), as well as the sacral inclination, PI, and PT (Pearson correlation coefficient, P=0.05). Meanwhile, no correlation was shown in the S2 incidence and SS. A significant difference in the lumbosacral angle, slip angle, L5 incidence, PI, L5 slope, sacral inclination, and PT was shown between the patients with high-grade spondylolisthesis and patients with low-grade spondylolisthesis. Among the aforementioned measurements, the PI showed a significant difference between the 2 groups and also had a significant correlation with the dislocation level in all the patients.

Establishing the Learning Curve of Robotic Sacral Colpopexy in a Start-up Robotics Program.

PubMed

Sharma, Shefali; Calixte, Rose; Finamore, Peter S

2016-01-01

To determine the learning curve of the following segments of a robotic sacral colpopexy: preoperative setup, operative time, postoperative transition, and room turnover. A retrospective cohort study to determine the number of cases needed to reach points of efficiency in the various segments of a robotic sacral colpopexy (Canadian Task Force II-2). A university-affiliated community hospital. Women who underwent robotic sacral colpopexy at our institution from 2009 to 2013 comprise the study population. Patient characteristics and operative reports were extracted from a patient database that has been maintained since the inception of the robotics program at Winthrop University Hospital and electronic medical records. Based on additional procedures performed, 4 groups of patients were created (A-D). Learning curves for each of the segment times of interest were created using penalized basis spline (B-spline) regression. Operative time was further analyzed using an inverse curve and sequential grouping. A total of 176 patients were eligible. Nonparametric tests detected no difference in procedure times between the 4 groups (A-D) of patients. The preoperative and postoperative points of efficiency were 108 and 118 cases, respectively. The operative points of proficiency and efficiency were 25 and 36 cases, respectively. Operative time was further analyzed using an inverse curve that revealed that after 11 cases the surgeon had reached 90% of the learning plateau. Sequential grouping revealed no significant improvement in operative time after 60 cases. Turnover time could not be assessed because of incomplete data. There is a difference in the operative time learning curve for robotic sacral colpopexy depending on the statistical analysis used. The learning curve of the operative segment showed an improvement in operative time between 25 and 36 cases when using B-spline regression. When the data for operative time was fit to an inverse curve, a learning rate of 11 cases was appreciated. Using sequential grouping to describe the data, no improvement in operative time was seen after 60 cases. Ultimately, we believe that efficiency in operative time is attained after 30 to 60 cases when performing robotic sacral colpopexy. The learning curve for preoperative setup and postoperative transition, which is reflective of anesthesia and nursing staff, was approximately 110 cases. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Ligament-induced sacral fractures of the pelvis are possible.

PubMed

Steinke, Hanno; Hammer, Niels; Lingslebe, Uwe; Höch, Andreas; Klink, Thomas; Böhme, Jörg

2014-07-01

Pelvic ring stability is maintained passively by both the osseous and the ligamentous apparatus. Therapeutic approaches focus mainly on fracture patterns, so ligaments are often neglected. When they rupture along with the bone after pelvic ring fractures, disrupting stability, ligaments need to be considered during reconstruction and rehabilitation. Our aim was to determine the influence of ligaments on open-book injury using two experimental models with body donors. Mechanisms of bone avulsion related to open-book injury were investigated. Open-book injuries were induced in human pelves and subsequently investigated by anatomical dissection and endoscopy. The findings were compared to CT and MRI scans of open-book injuries. Relevant structures were further analyzed using plastinated cross-sections of the posterior pelvic ring. A fragment of the distal sacrum was observed, related to open-book injury. Two ligaments were found to be responsible for this avulsion phenomenon: the caudal portion of the anterior sacroiliac ligament and another ligament running along the ventral surface of the third sacral vertebra. The sacral fragment remained attached to the coxal bone by this second ligament after open-book injury. These results were validated using plastination and the structures were identified. Pelvic ligaments are probably involved in sacral avulsion caused by lateral traction. Therefore, ligaments should to be taken into account in diagnosis of open-book injury and subsequent therapy. Copyright © 2014 Wiley Periodicals, Inc.

[Distribution of herpes simplex virus type 1 and 2 genomes in the human spinal ganglia].

PubMed

Obara, Y

1994-09-01

Herpes simplex virus (HSV) is well known for its propensity to cause recurrent oral or genital mucosal infections in humans. HSV-1 is involved primarily in oral lesions, whereas HSV-2 is more frequently involved in genital lesions. Based on this, it is thought that HSV-1 may produce latent infections in trigeminal ganglia, and HSV-2 in the sacral ganglia. However the distribution pattern of latent HSV-1 and HSV-2 infections in spinal ganglia remains unknown. Using the polymerase chain reaction we detected latent herpes HSV-1 and HSV-2 in human spinal ganglia obtained from autopsy material. A pair of primers which were specific for a part of the HSV-1 and HSV-2 DNA polymerase domain were employed. HSV-1 and HSV-2 DNAs were detected in 11 of 40 (28%) and 15 of 40 (38%) cervical ganglia, respectively, 52 of 103 (50%) and 47 of 103 (46%) thoracic ganglia, 16 of 53 (30%) and 17 of 53 (32%) lumbar ganglia, and 3 of 20 (15%) and 3 of 20 (15%) sacral ganglia. These findings suggest that latent HSV-1 and HSV-2 infections have a widespread distribution from the cervical ganglia to sacral ganglia. Importantly this study demonstrated latent HSV-1 infection of both the lumbar and sacral ganglia for the first time.

A common neural element receiving rhythmic arm and leg activity as assessed by reflex modulation in arm muscles.

PubMed

Sasada, Syusaku; Tazoe, Toshiki; Nakajima, Tsuyoshi; Futatsubashi, Genki; Ohtsuka, Hiroyuki; Suzuki, Shinya; Zehr, E Paul; Komiyama, Tomoyoshi

2016-04-01

Neural interactions between regulatory systems for rhythmic arm and leg movements are an intriguing issue in locomotor neuroscience. Amplitudes of early latency cutaneous reflexes (ELCRs) in stationary arm muscles are modulated during rhythmic leg or arm cycling but not during limb positioning or voluntary contraction. This suggests that interneurons mediating ELCRs to arm muscles integrate outputs from neural systems controlling rhythmic limb movements. Alternatively, outputs could be integrated at the motoneuron and/or supraspinal levels. We examined whether a separate effect on the ELCR pathways and cortico-motoneuronal excitability during arm and leg cycling is integrated by neural elements common to the lumbo-sacral and cervical spinal cord. The subjects performed bilateral leg cycling (LEG), contralateral arm cycling (ARM), and simultaneous contralateral arm and bilateral leg cycling (A&L), while ELCRs in the wrist flexor and shoulder flexor muscles were evoked by superficial radial (SR) nerve stimulation. ELCR amplitudes were facilitated by cycling tasks and were larger during A&L than during ARM and LEG. A low stimulus intensity during ARM or LEG generated a larger ELCR during A&L than the sum of ELCRs during ARM and LEG. We confirmed this nonlinear increase in single motor unit firing probability following SR nerve stimulation during A&L. Furthermore, motor-evoked potentials following transcranial magnetic and electrical stimulation did not show nonlinear potentiation during A&L. These findings suggest the existence of a common neural element of the ELCR reflex pathway that is active only during rhythmic arm and leg movement and receives convergent input from contralateral arms and legs. Copyright © 2016 the American Physiological Society.

Intralesional hemorrhage and thrombosis without rupture in a pure spinal epidural cavernous angioma: a rare cause of acute lumbal radiculopathy

PubMed Central

Riemenschneider, Markus; Herdmann, Jörg

2010-01-01

Pure spinal epidural cavernous angiomas are extremely rare lesions, and their normal shape is that of a fusiform mass in the dorsal aspects of the spinal canal. We report a case of a lumbo-sacral epidural cavernous vascular malformation presenting with acute onset of right-sided S1 radiculopathy. Clinical aspects, imaging, intraoperative findings, and histology are demonstrated. The patient, a 27-year-old man presented with acute onset of pain, paraesthesia, and numbness within the right leg corresponding to the S1 segment. An acute lumbosacral disc herniation was suspected, but MRI revealed a cystic lesion with the shape of a balloon, a fluid level and a thickened contrast-enhancing wall. Intraoperatively, a purple-blue tumor with fibrous adhesions was located between the right S1 and S2 nerve roots. Macroscopically, no signs of epidural bleedings could be denoted. After coagulation of a reticular venous feeder network and dissection of the adhesions the rubber ball-like lesion was resected in total. Histology revealed a prominent venous vessel with a pathologically thickened, amuscular wall surrounded by smaller, hyalinized, venous vessels arranged in a back-to-back position typical for the diagnosis of a cavernous angioma. Lumina were partially occluded by thrombi. The surrounding fibrotic tissue showed signs of recurrent bleedings. There was no obvious mass hemorrhage into the surrounding tissue. In this unique case, the pathologic mechanism was not the usual rupture of the cavernous angioma with subsequent intraspinal hemorrhage, but acute mass effect by intralesional bleedings and thrombosis with subsequent increase of volume leading to nerve root compression. Thus, even without a sudden intraspinal hemorrhage a spinal cavernous malformation can cause acute symptoms identical to the clinical features of a soft disc herniation. PMID:20213297

The sacroiliac joint: anatomy, physiology and clinical significance.

PubMed

Forst, Stacy L; Wheeler, Michael T; Fortin, Joseph D; Vilensky, Joel A

2006-01-01

The sacroiliac joint (SIJ) is a putative source of low back pain. The objective of this article is to provide clinicians with a concise review of SIJ structure and function, diagnostic indicators of SIJ-mediated pain, and therapeutic considerations. The SIJ is a true diarthrodial joint with unique characteristics not typically found in other diarthrodial joints. The joint differs with others in that it has fibrocartilage in addition to hyaline cartilage, there is discontinuity of the posterior capsule, and articular surfaces have many ridges and depressions. The sacroiliac joint is well innervated. Histological analysis of the sacroiliac joint has verified the presence of nerve fibers within the joint capsule and adjoining ligaments. It has been variously described that the sacroiliac joint receives its innervation from the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1, and S2, or that it is almost exclusively derived from the sacral dorsal rami. Even though the sacroiliac joint is a known putative source of low back and lower extremity pain, there are few findings that are pathognomonic of sacroiliac joint pain. The controlled diagnostic blocks utilizing the International Association for the Study of Pain (IASP) criteria demonstrated the prevalence of pain of sacroiliac joint origin in 19% to 30% of the patients suspected to have sacroiliac joint pain. Conservative management includes manual medicine techniques, pelvic stabilization exercises to allow dynamic postural control, and muscle balancing of the trunk and lower extremities. Interventional treatments include sacroiliac joint, intra-articular joint injections, radiofrequency neurotomy, prolotherapy, cryotherapy, and surgical treatment. The evidence for intra-articular injections and radiofrequency neurotomy has been shown to be limited in managing sacroiliac joint pain.

Radial nerve injury following elbow external fixator: report of three cases and literature review.

PubMed

Trigo, Luis; Sarasquete, Juan; Noguera, Laura; Proubasta, Ignacio; Lamas, Claudia

2017-07-01

Radial nerve palsy is a rare but serious complication following elbow external fixation. Only 11 cases have been reported in the literature to date, but the incidence may be underreported. We present three new cases of this complication. We analyzed the three cases of radial palsy seen in our center following the application of an external fixator as treatment for complex elbow injuries. Mean patient age at surgery was 50 years. Two patients were female and one was male. In the three cases, the initial lesion was a posterior elbow dislocation, associated with a fracture of the radial shaft in one and a radial head fracture and coronoid fracture, respectively, in the other two. Due to persistent elbow instability, an external fixator was applied in all three cases. The fixator pins were introduced percutaneously in two cases and under direct vision in an open manner in the third case. Radial palsy was noted immediately postoperatively in all cases. It was permanent in two cases and temporary in the third. Radial nerve palsy after placement of an external elbow fixator was resolved in only 1 of our 3 cases and in 6 of the 11 cases in the literature to date. Although the event is rare, these alarming results highlight the need for recommendations to avoid this complication.

Vitreoretinal complications and vitreoretinal surgery in osteo-odonto-keratoprosthesis surgery.

PubMed

Lim, Laurence S; Ang, Chong Lye; Wong, Edmund; Wong, Doric W K; Tan, Donald T H

2014-02-01

To describe the indications for and approaches to vitreoretinal surgery in patients with osteo-odonto-keratoprosthesis (OOKP). Retrospective case series. This was a retrospective review of all patients who had undergone OOKP surgery between 2003 and 2012 at our center. OOKP procedures were performed for severe ocular surface disease according to the indications and techniques described in the patient demographics of the Rome-Vienna Protocol. Indications for retinal surgery, surgical outcomes, and intraoperative and postoperative complications were documented. Operative techniques were reviewed from the surgical records, and any subsequent surgeries were also recorded. Thirty-six patients underwent OOKP, and retinal surgery was indicated in 13 (36%). The indications for and approaches to surgery were retinal detachment repair using an Eckardt temporary keratoprosthesis; assessment of retina and optic nerve health prior to OOKP surgery, using either a temporary keratoprosthesis or an endoscope; endoscopic cyclophotocoagulation for intractable glaucoma; endoscopic trimming of a retroprosthetic membrane; or vitrectomy for endophthalmitis with visualization through the OOKP optic using the binocular indirect viewing system. In all cases, retinal surgical aims were achieved with a single procedure. Postoperative vitreous hemorrhage occurred in 16 patients (44%), but all resolved spontaneously. OOKPs represent the last hope for restoration of vision in severe ocular surface disease, and the retinal surgeon is frequently called upon in the assessment and management of these patients. Temporary keratoprostheses and endoscopic vitrectomies are valuable surgical tools in these challenging cases, improving functional outcomes without compromising OOKP success. Copyright © 2014 Elsevier Inc. All rights reserved.

Risk factors for explantation due to infection after sacral neuromodulation: a multicenter retrospective case-control study.

PubMed

Myer, Emily N B; Petrikovets, Andrey; Slocum, Paul D; Lee, Toy Gee; Carter-Brooks, Charelle M; Noor, Nabila; Carlos, Daniela M; Wu, Emily; Van Eck, Kathryn; Fashokun, Tola B; Yurteri-Kaplan, Ladin; Chen, Chi Chiung Grace

2018-04-07

Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fecal incontinence. Infection after sacral neurostimulation is costly and burdensome. Determining optimal perioperative management strategies to reduce the risk of infection is important to reduce this burden. We sought to identify risk factors associated with sacral neurostimulator infection requiring explantation, to estimate the incidence of infection requiring explantation, and identify associated microbial pathogens. This is a multicenter retrospective case-control study of sacral neuromodulation procedures completed from Jan. 1, 2004, through Dec. 31, 2014. We identified all sacral neuromodulation implantable pulse generator implants as well as explants due to infection at 8 participating institutions. Cases were patients who required implantable pulse generator explantation for infection during the review period. Cases were included if age ≥18 years old, follow-up data were available ≥30 days after implantable pulse generator implant, and the implant was performed at the institution performing the explant. Two controls were matched to each case. These controls were the patients who had an implantable pulse generator implanted by the same surgeon immediately preceding and immediately following the identified case who met inclusion criteria. Controls were included if age ≥18 years old, no infection after implantable pulse generator implant, follow-up data were available ≥180 days after implant, and no explant for any reason <180 days from implant. Controls may have had an explant for reasons other than infection at >180 days after implant. Fisher exact test (for categorical variables) and Student t test (for continuous variables) were used to test the strength of the association between infection and patient and surgery characteristics. Significant variables were then considered in a multivariable logistic regression model to determine risk factors independently associated with infection. Over a 10-year period at 8 academic institutions, 1930 sacral neuromodulator implants were performed by 17 surgeons. In all, 38 cases requiring device explant for infection and 72 corresponding controls were identified. The incidence of infection requiring explant was 1.97%. Hematoma formation (13% cases, 0% controls; P = .004) and pocket depth of ≥3 cm (21% cases, 0% controls; P = .031) were independently associated with an increased risk of infection requiring explant. On multivariable regression analysis controlling for significant variables, both hematoma formation (P = .006) and pocket depth ≥3 cm (P = .020, odds ratio 3.26; 95% confidence interval, 1.20-8.89) remained significantly associated with infection requiring explant. Of the 38 cases requiring explant, 32 had cultures collected and 24 had positive cultures. All 5 cases with a hematoma had a positive culture (100%). Of the 4 cases with a pocket depth ≥3 cm, 2 had positive cultures, 1 had negative cultures, and 1 had a missing culture result. The most common organism identified was methicillin-resistant Staphylococcus aureus (38%). Infection after sacral neuromodulation requiring device explant is low. The most common infectious pathogen identified was methicillin-resistant S aureus. Demographic and health characteristics did not predict risk of explant due to infection, however, having a postoperative hematoma or a deep pocket ≥3 cm significantly increased the risk of explant due to infection. These findings highlight the importance of meticulous hemostasis as well as ensuring the pocket depth is <3 cm at the time of device implant. Copyright © 2018 Elsevier Inc. All rights reserved.

When do anterior external or internal fixators provide additional stability in an unstable (Tile C) pelvic fracture? A biomechanical study.

PubMed

Mcdonald, E; Theologis, A A; Horst, P; Kandemir, U; Pekmezci, M

2015-12-01

This study aimed at evaluating the additional stability that is provided by anterior external and internal fixators in an unstable pelvic fracture model (OTA 61-C). An unstable pelvic fracture (OTA 61-C) was created in 27 synthetic pelves by making a 5-mm gap through the sacral foramina (posterior injury) and an ipsilateral pubic rami fracture (anterior injury). The posterior injury was fixed with either a single iliosacral (IS) screw, a single trans-iliac, trans-sacral (TS) screw, or two iliosacral screws (S1S2). Two anterior fixation techniques were utilized: external fixation (Ex-Fix) and supra-acetabular external fixation and internal fixation (In-Fix); supra-acetabular pedicle screws connected with a single subcutaneous spinal rod. The specimens were tested using a nondestructive single-leg stance model. Peak-to-peak (P2P) displacement and rotation and conditioning displacement (CD) were calculated. The Ex-Fix group failed in 83.3 % of specimens with concomitant single-level posterior fixation (Total: 15/18-7 of 9 IS fixation, 8 of 9 TS fixation), and 0 % (0/9) of specimens with concomitant two-level (S1S2) posterior fixation. All specimens with the In-Fix survived testing except for two specimens treated with In-Fix combined with IS fixation. Trans-sacral fixation had higher pubic rotation and greater sacral and pubic displacement than S1S2 (p < 0.05). Rotation of the pubis and sacrum was not different between In-Fix constructs combined with single-level IS and TS fixation. In this model of an unstable pelvic fracture (OTA 61-C), anterior fixation with an In-Fix was biomechanically superior to an anterior Ex-Fix in the setting of single-level posterior fixation. There was no biomechanical difference between the In-Fix and Ex-Fix when each was combined with two levels of posterior sacral fixation.

A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine.

PubMed

Merc, Matjaz; Drstvensek, Igor; Vogrin, Matjaz; Brajlih, Tomaz; Recnik, Gregor

2013-07-01

The method of free-hand pedicle screw placement is generally safe although it carries potential risks. For this reason, several highly accurate computer-assisted systems were developed and are currently on the market. However, these devices have certain disadvantages. We have developed a method of pedicle screw placement in the lumbar and sacral region using a multi-level drill guide template, created with the rapid prototyping technology and have validated it in a clinical study. The aim of the study was to manufacture and evaluate the accuracy of a multi-level drill guide template for lumbar and first sacral pedicle screw placement and to compare it with the free-hand technique under fluoroscopy supervision. In 2011 and 2012, a randomized clinical trial was performed on 20 patients. 54 screws were implanted in the trial group using templates and 54 in the control group using the fluoroscopy-supervised free-hand technique. Furthermore, applicability for the first sacral level was tested. Preoperative CT-scans were taken and templates were designed using the selective laser sintering method. Postoperative evaluation and statistical analysis of pedicle violation, displacement, screw length and deviation were performed for both groups. The incidence of cortex perforation was significantly reduced in the template group; likewise, the deviation and displacement level of screws in the sagittal plane. In both groups there was no significantly important difference in deviation and displacement level in the transversal plane as not in pedicle screw length. The results for the first sacral level resembled the main investigated group. The method significantly lowers the incidence of cortex perforation and is therefore potentially applicable in clinical practice, especially in some selected cases. The applied method, however, carries a potential for errors during manufacturing and practical usage and therefore still requires further improvements.

The effect of low force chiropractic adjustments on body surface electromagnetic field.

PubMed

Zhang, John; Snyder, Brian J; Vernor, Lori

2004-03-01

The purpose of this study was to investigate the body surface electromagnetic field (EMF) changes using a sensitive magnetometer before and after a specific Toftness chiropractic adjustment in asymptomatic human subjects. Forty-four subjects were randomly assigned into control (20 subjects) and experimental groups (24 subjects) in a pre and post-test design. The Triaxial Fluxgate Magnetometer FGM-5DTAA (Walker Scientific, Worcester, Massachusetts) with five digit display and resolution of 1 nanotesla (nT) was used for EMF detection. The EMF in the research room and on the adjustment table was monitored and recorded. The subjects' body surface (cervical, thoracic, lumbar and sacral areas) EMF was determined in the prone position before and after the chiropractic adjustment. A low force Toftness chiropractic adjustment was applied to the cervical, thoracic, lumbar and sacral areas as determined by the practitioner. The EMF in the research room was recorded as 41611 nT at the Z axis (earth field), 13761 nT at the X axis and 7438 nT at the Y axis. The EMF on the adjusting table changed minimally during the 15 minute observation period. The EMF on the subjects' body surface decreased at 4 spinal locations after chiropractic adjustment. The EMF (mean +/- SD in nT) decreased significantly at the cervical region from 42449 +/- 907 to 41643 +/- 1165 (p < 0.01) and at the sacral regions from 43206 +/- 760 to 42713 +/- 552 (p < 0.01). The EMF at the lumbar and thoracic regions decreased but did not reach a statistically significant level. No significant changes of the body surface EMF were found in the control group. A low force Toftness chiropractic adjustment in the cervical and sacral areas resulted in a significant reduction of the cervical and sacral surface EMF. No significant body surface EMF changes were observed in the lumbar and thoracic regions. The mechanisms of the EMF reduction after chiropractic adjustment are not known.

The effect of low force chiropractic adjustments on body surface electromagnetic field

PubMed Central

Zhang, John; Snyder, Brian J; Vernor, Lori

2004-01-01

Objective The purpose of this study was to investigate the body surface electromagnetic field (EMF) changes using a sensitive magnetometer before and after a specific Toftness chiropractic adjustment in asymptomatic human subjects. Method Forty-four subjects were randomly assigned into control (20 subjects) and experimental groups (24 subjects) in a pre and post-test design. The Triaxial Fluxgate Magnetometer FGM-5DTAA (Walker Scientific, Worcester, Massachusetts) with five digit display and resolution of 1 nanotesla (nT) was used for EMF detection. The EMF in the research room and on the adjustment table was monitored and recorded. The subjects’ body surface (cervical, thoracic, lumbar and sacral areas) EMF was determined in the prone position before and after the chiropractic adjustment. A low force Toftness chiropractic adjustment was applied to the cervical, thoracic, lumbar and sacral areas as determined by the practitioner. Results The EMF in the research room was recorded as 41611 nT at the Z axis (earth field), 13761 nT at the X axis and 7438 nT at the Y axis. The EMF on the adjusting table changed minimally during the 15 minute observation period. The EMF on the subjects’ body surface decreased at 4 spinal locations after chiropractic adjustment. The EMF (mean ± SD in nT) decreased significantly at the cervical region from 42449 ± 907 to 41643 ± 1165 (p < 0.01) and at the sacral regions from 43206 ± 760 to 42713 ± 552 (p < 0.01). The EMF at the lumbar and thoracic regions decreased but did not reach a statistically significant level. No significant changes of the body surface EMF were found in the control group. Conclusion A low force Toftness chiropractic adjustment in the cervical and sacral areas resulted in a significant reduction of the cervical and sacral surface EMF. No significant body surface EMF changes were observed in the lumbar and thoracic regions. The mechanisms of the EMF reduction after chiropractic adjustment are not known. PMID:17549217

Pelvic X-ray misses out on detecting sacral fractures in the elderly - Importance of CT imaging in blunt pelvic trauma.

PubMed

Schicho, Andreas; Schmidt, Stefan A; Seeber, Kevin; Olivier, Alain; Richter, Peter H; Gebhard, Florian

2016-03-01

Patients aged 75 years and older with blunt pelvic trauma are frequently seen in the ER. The standard diagnostic tool in these patients is the plain a.p.-radiograph of the pelvis. Especially lesions of the posterior pelvic ring are often missed due to e.g. bowel gas projection and enteric overlay. With a retrospective study covering these patients over a 3 year period in our level I trauma centre, we were able to evaluate the rate of missed injuries in the a.p.-radiograph whenever a corresponding CT scan was performed. Age, gender, and accompanying fractures of the pelvic ring were recorded. The intrinsic test characteristics and the performance in the population were calculated according to standard formulas. Thus, 233 consecutive patients with blunt pelvic trauma with both conventional radiographic examination and computed tomography (CT) were included. Thereof, 56 (23%) showed a sacral fracture in the CT scan. Of 233 pelvic X-ray-images taken, 227 showed no sacral fracture. 51 (21.7%) of these were false negative, yielding a sensitivity of just 10.5%. Average age of patients with sacral fractures was 85.1±6.1 years, with 88% being female. Sacral fractures were often accompanied by lesions of the anterior pelvic ring with pubic bone fractures in 75% of sacrum fracture cases. Second most concomitant fractures are found at the acetabulum (23.3%). Plain radiographic imaging is especially likely to miss out fractures of the posterior pelvic ring, which nowadays can be of therapeutic consequence. Besides the physicians experience in the ED, profound knowledge of insensitivity of plain radiographs in finding posterior pelvic ring lesions is crucial for a reliable diagnostic routine. Since the high mortality caused by prolonged immobilisation due to pelvic ring injuries, all fractures should be identified. We therefore provide a diagnostic algorithm for blunt pelvic trauma in the elderly. Copyright © 2016 Elsevier Ltd. All rights reserved.

Safety and effectiveness of percutaneous sacroplasty: a single-centre experience in 58 consecutive patients with tumours or osteoporotic insufficient fractures treated under fluoroscopic guidance.

PubMed

Pereira, Licia Pacheco; Clarençon, Frédéric; Cormier, Evelyne; Rose, Michèle; Jean, Beatrix; Le Jean, Lise; Chiras, Jacques

2013-10-01

To report our experience in percutaneous sacroplasty (PSP) for tumours and insufficiency fractures of the sacrum. Single-centre retrospective analysis of 58 consecutive patients who underwent 67 PSPs for intractable pain from sacral tumours (84.5 %) or from osteoporotic fractures (15.5 %). The following data were assessed: visual analogue scale (VAS) before and after the procedure for global pain; short-term (1-month) clinical follow-up using a four-grade patient satisfaction scale (worse, unchanged, mild improvement and significant improvement); modification in analgesics consumption; referred short-term walking mobility. Minor and major complications were systematically assessed. The mean VAS score was 5.3 ± 2.0 in pre-procedure and 1.7 ± 1.8 in post-procedure. At 1-month follow-up, 34/58 (58.5 %) patients experienced a mild improvement; 15/58 (26 %) presented a significant improvement while 4/58 (7 %) and 5/58 (8.5 %) patients had unchanged or worse pain, respectively. Decreased analgesic consumption was observed in 34 % (20/58) of the patients. Eighty percent of patients with walking limitation experienced improvement, 16 % remained unchanged and 4 % were worse. We noted minor complications in 2/58 patients (3.4 %) and major complications in 2/58 patients (3.4 %). Percutaneous sacroplasty for metastatic and osteoporotic fractures is a safe and effective technique in terms of pain relief and functional outcome. • Percutaneous sacroplasty provides pain relief and functional improvement for insufficiency sacral fractures. • Percutaneous sacroplasty provides pain relief and function improvement for sacral tumours. • The major complication rate is acceptable (3.4 %), and is higher in sacral tumours. • Posterior wall/cortical sacral bone disruption is not statistically associated with more complications. • However, osteolytic tumours seem to be associated with higher risk of complications.

[PELVIS/SACRAL syndrome with livedoid haemangioma and amniotic band].

PubMed

Bourrat, E; Lemarchand-Venencie, F; Jacquemont, M-L; El Ghoneimi, A; Wassef, M; Leger, J; Morel, P

2008-12-01

PELVIS or SACRAL syndrome denotes the association of local haemangioma and malformation in the pelvic region. In this paper, we report a case noteworthy on account of the initially livedoid appearance of the haemangioma as well as associated amniotic banding of an upper limb. A newborn male infant underwent left colostomy on the day of birth due to anal imperforation and anomalies of the external genital organs with sexual ambiguity. Examination of the skin and appendages revealed poorly delineated hypopigmentation in the sacrolumbar region and a fibrous groove around the right arm characteristic of amniotic band syndrome. Sacrolumbar and pelvic MRI scans revealed deviation towards the left of the last three sacral vertebrae with no medullary anomalies. Retrograde cystography showed a recto-uretral fistula. Progression of the infant's condition was marked by the appearance during the first month of a flat, violaceous, angiomatous, livedoid lesion in the middle of the buttocks and the perineum and a linear lesion on the rear aspect of the right lower limb. The skin biopsy of this lesion revealed a single capillary lobule at the dermal-hypodermal junction of non-specific appearance but with marked Glut1 expression by endothelial cells highly evocative of infantile haemangioma. Segmented haemangiomas are commonly associated with extracutaneous abnormalities. By analogy with PHACE syndrome, defined as association of segmented facial haemangioma with cerebral, ocular and cardio-aortic abnormalities, PELVIS/SACRAL syndrome denotes the association of segmented haemangioma of the loins (sacrolumbar region, buttocks or perineum=napkin haemangioma) with spinal dysraphia affecting the sacrolumbar spine, the terminal medullary cone, the genitourinary organs and the anal region to different degrees. Diagnosis of haemangioma associated with PELVIS/SACRAL syndrome may be delayed or complicated due to the macular, telangiectasic or livedoid appearance commonly seen. To our knowledge, there have been no reports to date of an association of amniotic banding with haemangioma or perineal dysraphia.

The surgical management of sacral chordomas.

PubMed

Schwab, Joseph H; Healey, John H; Rose, Peter; Casas-Ganem, Jorge; Boland, Patrick J

2009-11-15

Retrospective case series. The purpose of this study was to evaluate factors that contribute to improved local control and survival. In addition, we sought to define the expected morbidity associated with treatment. Sacral chordomas are rare tumors presumed to arise from notochordal cells. Local recurrence presents a major problem in the management of these tumors and it has been correlated with survival. Resection of sacral tumors is associated with significant morbidity. Forty-two patients underwent resection for sacral chordoma between 1990 and 2005. Twelve patients had their initial surgery elsewhere. There were 12 female and 30 male patients. The proximal extent of the sacrectomy was at least S2 in 32 patients. Median survival was 84 months, and 5-year disease-free (DFS) and disease-specific survival (DSF) were 56% and 77%, respectively. Local recurrence (LR) and metastasis occurred in 17 (40%) and 13 (31%) patients, respectively. Local recurrence (P=0.0001), metastasis (P=0.0001), prior resection (P=0.046), and higher grade (P=0.05) were associated with a worse DSF. Prior resections (P=0.0001) and intralesional resections (P=0.01) were associated with a higher rate of LR. Intralesional resections were associated with a lower DSF (P=0.0001). Wide contaminated margins treated with cryosurgery and/or radiation were not associated with a higher LR rate. Rectus abdominus flaps were associated with decreased wound complications (P=0.01). Thirty-one (74%) patients reported that they self catheterize; and 16 (38%) patients required bowel training, while an additional twelve (29%) patients had a colostomy. Twenty-eight (67%) patients reported sexual dysfunction. Two (5%) patients died due to sepsis. Intralesional resection should be avoided as it is associated with a higher LR rate and worse survival. Rectus abdominus flaps ought to be considered as they lower the wound complication rate. Sacral resection is associated with significant morbidity.

Influence of lumbar lordosis restoration on thoracic curve and sagittal position in lumbar degenerative kyphosis patients.

PubMed

Jang, Jee-Soo; Lee, Sang-Ho; Min, Jun-Hong; Maeng, Dae Hyeon

2009-02-01

A retrospective study. To determine postsurgical correlations between thoracic and lumbar sagittal curves in lumbar degenerative kyphosis (LDK) and to determine predictability of spontaneous correction of thoracic curve and sacral angle after surgical restoration of lumbar lordosis and fusion. To our knowledge, there are only a limited number of articles about the relationship between thoracic and lumbar curve in sagittal thoracic compensated LDK. Retrospective review of 53 consecutive patients treated with combined anterior and posterior spinal arthrodesis. We included patients with sagittal thoracic compensated LDK caused by sagittal imbalance in this study. Total lumbar lordosis, thoracic kyphosis, sacral slope, and C7 plumb line were measured on the pre- and postoperative whole spine lateral views. Postoperative changes in thoracic kyphosis, sacral slope, and C7 plumb line according to the surgical lumbar lordosis restoration were measured and evaluated. The mean preoperative sagittal imbalance by plumb line was 78.3 mm (+/-76.5); this improved to 13.6 mm (+/-25) after surgery (P < 0.0001). Mean lumbar lordosis was 9.4 degrees (+/-19.2) before surgery and increased to 38.4 degrees (+/-13.1) at follow-up (P < 0.0001). Mean thoracic kyphosis was 1.1 degrees (+/-12.7) before surgery and increased to 17.6 degrees (+/-12.2) at follow-up (P < 0.0001). Significant preoperative correlations existed between kyphosis and lordosis (r = 0.772, P < 0.0001) and between lordosis and sacral slope (r = 0.785, P < 0.0001). Postoperative lumbar lordosis is correlated to thoracic kyphosis increase (r = 0.620, P < 0.0001). Postoperative lumbar lordosis is correlated to sacral slope increase (r = 0.722, P < 0.0001). Reciprocal relationship exists between lumbar lordosis and thoracic kyphosis in sagittal thoracic compensated LDK. Surgical restoration of lumbar lordosis for LDK brings about high level of statistical correlation to thoracic kyphosis improvement. At the same time, the reciprocal relationship is maintained.

Urodynamic results, clinical efficacy, and complication rates of sacral intradural deafferentation and sacral anterior root stimulation in patients with neurogenic lower urinary tract dysfunction resulting from complete spinal cord injury.

PubMed

Krasmik, D; Krebs, Jörg; van Ophoven, Arndt; Pannek, Jürgen

2014-11-01

To investigate the outcome and complications of sacral deafferentation (SDAF) and sacral anterior root stimulation (SARS) in patients with neurogenic lower urinary tract dysfunction (NLUTD) resulting from complete spinal cord injury (SCI). Retrospective chart analysis of 137 patients who underwent SDAF/SARS at a single institution. Patients were categorized as being at risk of renal damage when the maximum detrusor pressure was >40 cmH2 O or detrusor compliance was <20 ml/cmH2 O. After a mean follow-up time of 14.8 ± 5.3 years, SDAF/SARS treatment significantly (P < 0.001) reduced the number of patients suffering from elevated detrusor pressure from 65 to 2, and from low detrusor compliance from 62 to 13, respectively. Mean bladder capacity significantly (P < 0.001) improved from 272.4 ± 143.0 to 475.0 ± 82.7 ml. The mean number of symptomatic UTI also decreased significantly (P < 0.001) from 6.2 ± 4.5 to 2.5 ± 2.6 per year. The number of patients suffering from incontinence had significantly (P < 0.001) decreased from 70 to 44. At the last follow-up visit, 107 (78.1%) patients were still using the stimulator. A total of 84 complications requiring surgical revision were observed. Defects of the stimulator cables or the receiver plate were the most common events (n = 38). The retrospective design pertains to the limitations of the study. Sacral deafferentation and SARS are an effective treatment option for refractory NLUTD in patients with complete SCI, despite a substantial long-term complication rate. © 2014 Wiley Periodicals, Inc.

How is sagittal balance acquired during bipedal gait acquisition? Comparison of neonatal and adult pelves in three dimensions. Evolutionary implications.

PubMed

Tardieu, Christine; Bonneau, Noémie; Hecquet, Jérôme; Boulay, Christophe; Marty, Catherine; Legaye, Jean; Duval-Beaupère, Geneviève

2013-08-01

We compare adult and intact neonatal pelves, using a pelvic sagittal variable, the angle of sacral incidence, which presents significant correlations with vertebral curvature in adults and plays an important role in sagittal balance of the trunk on the lower limbs. Since the lumbar curvature develops in the child in association with gait acquisition, we expect a change in this angle during growth which could contribute to the acquisition of sagittal balance. To understand the mechanisms underlying the sagittal balance in the evolution of human bipedalism, we also measure the angle of incidence of hominid fossils. Fourty-seven landmarks were digitized on 50 adult and 19 intact neonatal pelves. We used a three-dimensional model of the pelvis (DE-VISU program) which calculates the angle of sacral incidence and related functional variables. Cross-sectional data from newborns and adults show that the angle of sacral incidence increases and becomes negatively correlated with the sacro-acetabular distance. During ontogeny the sacrum becomes curved, tends to sink down between the iliac blades as a wedge and moves backward in the sagittal plane relative to the acetabula, thus contributing to the backwards displacement of the center of gravity of the trunk. A chain of correlations links the degree of the sacral slope and of the angle of incidence, which is tightly linked with the lumbar lordosis. We sketch a model showing the coordinated changes occurring in the pelvis and vertebral column during the acquisition of bipedalism in infancy. In the australopithecine pelves, Sts 14 and AL 288-1, and in the Homo erectus Gona pelvis the angle of sacral incidence reaches the mean values of humans. Discussing the incomplete pelves of Ardipithecus ramidus, Australopithecus sediba and the Nariokotome Boy, we suggest how the functional linkage between pelvis and spine, observed in humans, could have emerged during hominid evolution. Copyright © 2013 Elsevier Ltd. All rights reserved.

THE RAPID SHALLOW BREATHING RESULTING FROM PULMONARY CONGESTION AND EDEMA

PubMed Central

Churchill, Edward D.; Cope, Oliver

1929-01-01

These experiments record the effects of the experimental production of pulmonary congestion and edema in a lung completely isolated from the general circulation, but with an intact nerve supply. The resulting changes are: a slowing of the heart rate, a fall in systemic blood pressure and a temporary inhibition of respiration succeeded by rapid shallow breathing. The pulse rate and blood pressure show a rapid and spontaneous return to initial conditions. The respirations show a partial but not a complete return to their former rate and depth. The effects on respiration are similar to those described by Dunn and Binger and Moore which follow multiple embolism of the pulmonary circuit with starch granules. The alterations in the pulse rate and blood pressure are characteristic of the effects of vagal stimulation. A chemical effect on the respiratory center is excluded by the nature of the preparation. These results, therefore, add further evidence to support the hypothesis that the rapid shallow breathing attending congestion and edema of the lungs is due to the stimulation of nerve endings in the lungs. PMID:19869562

Neuropathic pain resulting from implant placement: case report and diagnostic conclusions.

PubMed

Leckel, M; Kress, B; Schmitter, M

2009-07-01

Temporary or persisting dysesthesia of the nervus alveolaris inferior has often been described as a complication of implant surgery of the lower mandible. In most cases, lesion of the nerve results in anaesthesia of the innervated region, a symptom clearly indicative of correct diagnosis. In our case report, however, a minor perforation of the roof of the mandibular canal during implant placement apparently provoked discrete irritation of the nerve, resulting in persistent neuropathic pain without concomitant hypesthesia or dysesthesia. Because the canal could not be detected in conventional dental radiographs, this uncharacteristic situation made correct diagnosis difficult and led to unnecessary surgical procedures including extraction of adjacent teeth. Medical imaging [computed tomography (CT)] finally revealed the close proximity of the apex of the implant and the bony structure of the mandibular canal. The effect on the nervus alveolaris inferior was also demonstrated using an innovative high-resolution dental magnetic-resonance-imaging technique reflecting vascular reactions of the neurovascular bundle after potentially damaging surgical intervention. After removal of the causative implant, the pain gradually faded over a period of a year.

[Anatomy of the levator ani muscle and implications for obstetrics and gynaecology].

PubMed

Nyangoh Timoh, K; Bessede, T; Zaitouna, M; Peschaud, F; Chevallier, J-M; Fauconnier, A; Benoit, G; Moszkowicz, D

2015-01-01

Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery. Copyright © 2015. Published by Elsevier SAS.

Transfrontal orbitotomy in the dog: an adaptable three-step approach to the orbit.

PubMed

Håkansson, Nils Wallin; Håkansson, Berit Wallin

2010-11-01

To describe an adaptable and extensive method for orbitotomy in the dog. An adaptable three-step technique for orbitotomy was developed and applied in nine consecutive cases. The steps are zygomatic arch resection laterally, temporalis muscle elevation medially and zygomatic process osteotomy anteriorly-dorsally. The entire orbit is accessed with excellent exposure and room for surgical manipulation. Facial nerve, lacrimal nerve and lacrimal gland function are preserved. The procedure can easily be converted into an orbital exenteration. Exposure of the orbit was excellent in all cases and anatomically correct closure was achieved. Signs of postoperative discomfort were limited, with moderate, reversible swelling in two cases and mild in seven. Wound infection or emphysema did not occur, nor did any other complication attributable to the operative procedure. Blinking ability and lacrimal function were preserved over follow-up times ranging from 1 to 4 years. Transfrontal orbitotomy in the dog offers excellent exposure and room for manipulation. Anatomically correct closure is easily accomplished, postoperative discomfort is limited and complications are mild and temporary. © 2010 American College of Veterinary Ophthalmologists.

Urinary retention, erectile dysfunction and meningitis due to sacral herpes zoster: a case report and review of the literature.

PubMed

Erol, B; Avci, A; Eken, C; Ozgok, Y

2009-01-01

Zona zoster infection is often associated with painful erythematous vesicular eruptions of the skin or mucous membranes. Varicella zoster virus which stays latent in the sensorial root ganglia causes zona zoster infection. The most recognized feature of zona zoster is the dermatomal distribution of vesicular rashes. In the present case report, we state an unusual presentation of sacral zona zoster with urinary retention, erectile dysfunction and meningitis. Copyright 2009 S. Karger AG, Basel.

A new feature extraction method for signal classification applied to cord dorsum potentials detection

PubMed Central

Vidaurre, D.; Rodríguez, E. E.; Bielza, C.; Larrañaga, P.; Rudomin, P.

2012-01-01

In the spinal cord of the anesthetized cat, spontaneous cord dorsum potentials (CDPs) appear synchronously along the lumbo-sacral segments. These CDPs have different shapes and magnitudes. Previous work has indicated that some CDPs appear to be specially associated with the activation of spinal pathways that lead to primary afferent depolarization and presynaptic inhibition. Visual detection and classification of these CDPs provides relevant information on the functional organization of the neural networks involved in the control of sensory information and allows the characterization of the changes produced by acute nerve and spinal lesions. We now present a novel feature extraction approach for signal classification, applied to CDP detection. The method is based on an intuitive procedure. We first remove by convolution the noise from the CDPs recorded in each given spinal segment. Then, we assign a coefficient for each main local maximum of the signal using its amplitude and distance to the most important maximum of the signal. These coefficients will be the input for the subsequent classification algorithm. In particular, we employ gradient boosting classification trees. This combination of approaches allows a faster and more accurate discrimination of CDPs than is obtained by other methods. PMID:22929924

A new feature extraction method for signal classification applied to cord dorsum potential detection.

PubMed

Vidaurre, D; Rodríguez, E E; Bielza, C; Larrañaga, P; Rudomin, P

2012-10-01

In the spinal cord of the anesthetized cat, spontaneous cord dorsum potentials (CDPs) appear synchronously along the lumbo-sacral segments. These CDPs have different shapes and magnitudes. Previous work has indicated that some CDPs appear to be specially associated with the activation of spinal pathways that lead to primary afferent depolarization and presynaptic inhibition. Visual detection and classification of these CDPs provides relevant information on the functional organization of the neural networks involved in the control of sensory information and allows the characterization of the changes produced by acute nerve and spinal lesions. We now present a novel feature extraction approach for signal classification, applied to CDP detection. The method is based on an intuitive procedure. We first remove by convolution the noise from the CDPs recorded in each given spinal segment. Then, we assign a coefficient for each main local maximum of the signal using its amplitude and distance to the most important maximum of the signal. These coefficients will be the input for the subsequent classification algorithm. In particular, we employ gradient boosting classification trees. This combination of approaches allows a faster and more accurate discrimination of CDPs than is obtained by other methods.

Extra-skeletal Ewing sarcoma of the lumbosacral region in an adult pregnant patient: a case report.

PubMed

Al Khawaja, Darweesh; Vescovi, Cristina; Dower, Ashraf; Thiruvilangam, Vallapan; Mahasneh, Tamadur

2017-03-01

Extra-skeletal Ewing sarcoma in pregnancy is rare. There is thus limited scientific evidence to guide clinicians in its complicated management, particularly within the context of early gestation. We therefore share our successful outcome in a 32-year-old pregnant patient, following a unique management strategy of complete aggressive surgical resection prior to neo-adjuvant therapy. The case involved a 2-month history of right-sided back and gluteal pain, with associated paraesthesia. Lumbosacral magnetic resonance imaging (MRI) revealed an approximate 40×50 mm indeterminate mass in the lower right paraspinal musculature. The mass extended into the first right sacral foramen and the central canal; and also impinged on the S2 exiting nerve. After considering the patients' rapid deterioration, pregnant status and other clinical factors, it was elected to proceed with complete surgical resection prior to any other therapeutic modality. Following surgery, the patient experienced immediate resolution of her pain and by 6 weeks was able to cease the use of all analgesics. At 32-weeks' gestation she underwent an uncomplicated vaginal delivery. At 9 months follow up, she remains disease free and has experienced complete resolution of her back pain and radiculopathy.

Extra-skeletal Ewing sarcoma of the lumbosacral region in an adult pregnant patient: a case report

PubMed Central

Al Khawaja, Darweesh; Dower, Ashraf; Thiruvilangam, Vallapan; Mahasneh, Tamadur

2017-01-01

Extra-skeletal Ewing sarcoma in pregnancy is rare. There is thus limited scientific evidence to guide clinicians in its complicated management, particularly within the context of early gestation. We therefore share our successful outcome in a 32-year-old pregnant patient, following a unique management strategy of complete aggressive surgical resection prior to neo-adjuvant therapy. The case involved a 2-month history of right-sided back and gluteal pain, with associated paraesthesia. Lumbosacral magnetic resonance imaging (MRI) revealed an approximate 40×50 mm indeterminate mass in the lower right paraspinal musculature. The mass extended into the first right sacral foramen and the central canal; and also impinged on the S2 exiting nerve. After considering the patients’ rapid deterioration, pregnant status and other clinical factors, it was elected to proceed with complete surgical resection prior to any other therapeutic modality. Following surgery, the patient experienced immediate resolution of her pain and by 6 weeks was able to cease the use of all analgesics. At 32-weeks’ gestation she underwent an uncomplicated vaginal delivery. At 9 months follow up, she remains disease free and has experienced complete resolution of her back pain and radiculopathy. PMID:28435928

The potential of immunostimulatory CpG DNA for inducing immunity against genital herpes: opportunities and challenges.

PubMed

Harandi, Ali M

2004-07-01

Herpes simplex virus type 2 (HSV-2) invades human genital tract mucosa and following local replications can be rapidly transmitted via peripheral nerve axons to the sacral ganglia where it can establish latency. Reactivation of the latent viral reservoir results in recurrent ulcers in the genital region. Innate immunity, the first line of defence during both primary and recurrent genital herpes infections, is crucial during the period of acute infection to limit early virus replication and to facilitate the development of an appropriate specific acquired immunity. Recent developments in immunology reveal that the mammalian innate immune systems use Toll-like receptor (TLR) to specifically sense evolutionary conserved molecules such as bacterial DNA in pathogens. Recently, local-vaginal delivery of CpG containing oligodeoxynucleotide (ODN), a synthetic mimic of bacterial DNA, holds substantial promise as a strong inducer of innate immunity against genital herpes infections in the animal models of the disease. These preclinical observations provide a scientific ground work for introduction of this novel intervention strategy to clinic. This review aims to highlight recent developments and future challenges in use of immunostimulatory CpG ODN for inducing immunity against genital herpes infection and disease.

OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial.

PubMed

Amundsen, Cindy L; Richter, Holly E; Menefee, Shawn A; Komesu, Yuko M; Arya, Lily A; Gregory, W Thomas; Myers, Deborah L; Zyczynski, Halina M; Vasavada, Sandip; Nolen, Tracy L; Wallace, Dennis; Meikle, Susan F

2016-10-04

Women with refractory urgency urinary incontinence are treated with sacral neuromodulation and onabotulinumtoxinA with limited comparative information. To assess whether onabotulinumtoxinA is superior to sacral neuromodulation in controlling refractory episodes of urgency urinary incontinence. Multicenter open-label randomized trial (February 2012-January 2015) at 9 US medical centers involving 381 women with refractory urgency urinary incontinence. Cystoscopic intradetrusor injection of 200 U of onabotulinumtoxinA (n = 192) or sacral neuromodulation (n = 189). Primary outcome, change from baseline mean number of daily urgency urinary incontinence episodes over 6 months, was measured with monthly 3-day diaries. Secondary outcomes included change from baseline in urinary symptom scores in the Overactive Bladder Questionnaire Short Form (SF); range, 0-100, higher scores indicating worse symptoms; Overactive Bladder Satisfaction questionnaire; range, 0-100; includes 5 subscales, higher scores indicating better satisfaction; and adverse events. Of the 364 women (mean [SD] age, 63.0 [11.6] years) in the intention-to-treat population, 190 women in the onabotulinumtoxinA group had a greater reduction in 6-month mean number of episodes of urgency incontinence per day than did the 174 in the sacral neuromodulation group (-3.9 vs -3.3 episodes per day; mean difference, 0.63; 95% CI, 0.13 to 1.14; P = .01). Participants treated with onabotulinumtoxinA showed greater improvement in the Overactive Bladder Questionnaire SF for symptom bother (-46.7 vs -38.6; mean difference, 8.1; 95% CI, 3.0 to 13.3; P = .002); treatment satisfaction (67.7 vs 59.8; mean difference, 7.8; 95% CI, 1.6 to 14.1; P = .01) and treatment endorsement (78.1 vs 67.6; mean difference; 10.4, 95% CI, 4.3 to 16.5; P < .001) than treatment with sacral neuromodulation. There were no differences in convenience (67.6 vs 70.2; mean difference, -2.5; 95% CI, -8.1 to 3.0; P = .36), adverse effects (88.4 vs 85.1; mean difference, 3.3; 95% CI, -1.9 to 8.5; P = .22), and treatment preference (92.% vs 89%; risk difference, -3%; 95% CI, -16% to 10%; P = .49). Urinary tract infections were more frequent in the onabotulinumtoxinA group (35% vs 11%; risk difference, -23%; 95% CI, -33% to -13%; P < .001). The need for self-catheterization was 8% and 2% at 1 and 6 months in the onabotulinumtoxinA group. Neuromodulation device revisions and removals occurred in 3%. Among women with refractory urgency urinary incontinence, treatment with onabotulinumtoxinA compared with sacral neuromodulation resulted in a small daily improvement in episodes that although statistically significant is of uncertain clinical importance. In addition, it resulted in a higher risk of urinary tract infections and need for transient self-catheterizations.

Retroauricular transmeatal approach to manage mandibular condylar head fractures.

PubMed

Benech, Arnaldo; Arcuri, Francesco; Baragiotta, Nicola; Nicolotti, Matteo; Brucoli, Matteo

2011-03-01

There is a multitude of reported surgical approaches and technical variants with some unresolved technical problems to gain direct access to mandibular condylar head fractures; they can be divided into 2 groups: intraoral and extraoral. In 2005, Neff et al (Mund Kiefer Gesichtschir 2005;9:80), supported by a previous experimental work, reported a successful clinical study of condylar head fractures treated by a retroauricular approach; this article is in German, and the later English-language literature does not mention about this approach to open reduction and internal fixation of mandibular condylar fractures. The retroauricular transmeatal access, selected and performed by the senior author to treat 14 patients affected by highly located condylar head fracture, is illustrated in details. We collected data of 14 consecutive adult patients who, after the discussion about all options, had consented to have 16 mandibular condylar head fractures treated with open reduction and internal fixation by miniplates and screws via a retroauricular transmeatal approach. We exposed the temporomandibular joint area easily and better by dissecting via a retroauricular route with identification, ligation, and transection of the retromandibular vein; because of the posterior access, the frontal branch of the facial nerve and the auriculotemporal nerve are located and protected within the substance of the anteriorly retracted flap, superficial to the retromandibular vein. The follow-up clinical examination showed temporary weakness of the frontal branch of the facial nerve in 1 case with a recovery to normal function of 1.6 months; no patients had permanent weakness of the facial nerve or injury of the auriculotemporal nerve. There was absence of any salivary fistula, sialocele, and Frey syndrome; hearing was preserved in all cases, without any auditory stenosis or aesthetic deformity, and there was absence of any infections, hematoma, or scarring. Retroauricular approach provides good exposure of the temporomandibular joint and satisfactory protection from nerve injuries and vascular lesions, allowing an adequate osteosynthesis. The scar is hidden behind the ear, and the morbidity is low in terms of auditory stenosis, aesthetic deformity, and salivary fistulas.

Gamma Knife radiosurgery for facial nerve schwannomas: a multicenter study.

PubMed

Sheehan, Jason P; Kano, Hideyuki; Xu, Zhiyuan; Chiang, Veronica; Mathieu, David; Chao, Samuel; Akpinar, Berkcan; Lee, John Y K; Yu, James B; Hess, Judith; Wu, Hsiu-Mei; Chung, Wen-Yuh; Pierce, John; Missios, Symeon; Kondziolka, Douglas; Alonso-Basanta, Michelle; Barnett, Gene H; Lunsford, L Dade

2015-08-01

Facial nerve schwannomas (FNSs) are rare intracranial tumors, and the optimal management of these tumors remains unclear. Resection can be undertaken, but the tumor's intimate association with the facial nerve makes resection with neurological preservation quite challenging. Stereotactic radiosurgery (SRS) has been used to treat FNSs, and this study evaluates the outcome of this approach. At 8 medical centers participating in the North American Gamma Knife Consortium (NAGKC), 42 patients undergoing SRS for an FNS were identified, and clinical and radiographic data were obtained for these cases. Males outnumbered females at a ratio of 1.2:1, and the patients' median age was 48 years (range 11-76 years). Prior resection was performed in 36% of cases. The mean tumor volume was 1.8 cm(3), and a mean margin dose of 12.5 Gy (range 11-15 Gy) was delivered to the tumor. At a median follow-up of 28 months, tumor control was achieved in 36 (90%) of the 40 patients with reliable radiographic follow-up. Actuarial tumor control was 97%, 97%, 97%, and 90% at 1, 2, 3, and 5 years postradiosurgery. Preoperative facial nerve function was preserved in 38 of 42 patients, with 60% of evaluable patients having House-Brackmann scores of 1 or 2 at last follow-up. Treated patients with a House-Brackmann score of 1 to 3 were more likely to demonstrate this level of facial nerve function at last evaluation (OR 6.09, 95% CI 1.7-22.0, p = 0.006). Avoidance of temporary or permanent neurological symptoms was more likely to be achieved in patients who received a tumor margin dose of 12.5 Gy or less (log-rank test, p = 0.024) delivered to a tumor of ≤ 1 cm(3) in volume (log-rank test, p = 0.01). Stereotactic radiosurgery resulted in tumor control and neurological preservation in most FNS patients. When the tumor is smaller and the patient exhibits favorable normal facial nerve function, SRS portends a better result. The authors believe that early, upfront SRS may be the treatment of choice for small FNSs, but it is an effective salvage treatment for residual/recurrent tumor that remain or progress after resection.

Internal-Specific Morphological Analysis of Sciatic Nerve Fibers in a Radiofrequency-Induced Animal Neuropathic Pain Model

PubMed Central

Choi, Samjin; Choi, Hyuk Jai; Cheong, Youjin; Lim, Young-Jin; Park, Hun-Kuk

2013-01-01

This study investigated the reversible effects of pulsed radiofrequency (PRF) treatment at 42°C on the ultrastructural and biological changes in nerve and collagen fibers in the progression of neuropathic pain after rat sciatic nerve injury. Assessments of morphological changes in the extracellular matrices by atomic force microscopy and hematoxylin-eosin, Masson’s trichrome and picrosirius-red staining as well as the expressions of two fibril-forming collagens, types-I and -III, and two inflammatory cytokines, TNF-α and IL-6, were evaluated on day 30 after RF exposure. There were four groups for different RF thermal treatments: no treatment, no current, PRF, and continuous RF (CRF). An RF procedure similar to that used in human clinical trials was used in this study. The CRF treatment at 82°C led to neural and collagen damage by the permanent blockage of sensory nociceptors. The PRF treatment led to excellent performance and high expandability compared to CRF, with effects including slight damage and swelling of myelinated axons, a slightly decreased amount of collagen fibers, swelling of collagen fibril diameters, decreased immunoreactivity of collagen types-I and -III, presence of newly synthesized collagen, and recovery of inflammatory protein immunoreactivity. These evidence-based findings suggest that PRF-based pain relief is responsible for the temporary blockage of nerve signals as well as the preferential destruction of pain-related principal sensory fibers like the Aδ and C fibers. This suggestion can be supported by the interaction between the PRF-induced electromagnetic field and cell membranes; therefore, PRF treatment provides pain relief while allowing retention of some tactile sensation. PMID:24066083

Neurostimulation for bladder evacuation: is sacral root stimulation a substitute for microstimulation?

PubMed

Probst, M; Piechota, H J; Hohenfellner, M; Gleason, C A; Tanagho, E A

1997-04-01

To determine by anatomical and functional studies whether stimulation of sacral rootlets might permit selective stimulation of autonomic fibres, thus avoiding the detrusor/sphincter dyssynergia characteristic of current techniques of neurostimulation for bladder evacuation. In 10 male mongrel dogs, the S2 root was isolated and its constituent rootlets followed from their origin in the spinal cord to the point of exit from the dura. The entire root and the individual rootlets were then stimulated, including intra- and extra-dural stimulation and at proximal, mid and distal levels. Neuroanatomical and histological findings showed that rootlets of ventral S2 maintain their identity throughout their intradural course; some carry predominantly autonomic fibres, some predominantly somatic and some a mixture of the two. It appears surgically feasible to identify, isolate and sever the predominantly somatic rootlets intradurally, sparing the predominantly autonomic rootlets for inclusion in extradural electrode placement around the entire sacral root, thus eliminating sphincteric interference with detrusor contraction for voiding at low pressure.

Formation of the sacrum requires down-regulation of sonic hedgehog signaling in the sacral intervertebral discs.

PubMed

Bonavita, Raffaella; Vincent, Kathleen; Pinelli, Robert; Dahia, Chitra Lekha

2018-05-21

In humans, the sacrum forms an important component of the pelvic arch, and it transfers the weight of the body to the lower limbs. The sacrum is formed by collapse of the intervertebral discs (IVDs) between the five sacral vertebrae during childhood, and their fusion to form a single bone. We show that collapse of the sacral discs in the mouse is associated with the down-regulation of sonic hedgehog (SHH) signaling in the nucleus pulposus (NP) of the disc, and many aspects of this phenotype can be reversed by experimental postnatal activation of HH signaling. We have previously shown that SHH signaling is essential for the normal postnatal growth and differentiation of intervertebral discs elsewhere in the spine, and that loss of SHH signaling leads to pathological disc degeneration, a very common disorder of aging. Thus, loss of SHH is pathological in one region of the spine but part of normal development in another. © 2018. Published by The Company of Biologists Ltd.

The sacral autonomic outflow is parasympathetic: Langley got it right.

PubMed

Horn, John P

2018-04-01

A recent developmental study of gene expression by Espinosa-Medina, Brunet and colleagues sparked controversy by asserting a revised nomenclature for divisions of the autonomic motor system. Should we re-classify the sacral autonomic outflow as sympathetic, as now suggested, or does it rightly belong to the parasympathetic system, as defined by Langley nearly 100 years ago? Arguments for rejecting Espinosa-Medina, Brunet et al.'s scheme subsequently appeared in e-letters and brief reviews. A more recent commentary in this journal by Brunet and colleagues responded to these criticisms by labeling Langley's scheme as a historical myth perpetuated by ignorance. In reaction to this heated exchange, I now examine both sides to the controversy, together with purported errors by the pioneers in the field. I then explain, once more, why the sacral outflow should remain known as parasympathetic, and outline suggestions for future experimentation to advance the understanding of cellular identity in the autonomic motor system.

Refractory overactive bladder: Beyond oral anticholinergic therapy

PubMed Central

Glinski, Ronald W.; Siegel, Steven

2007-01-01

Objectives: In this review, we discuss the treatment of refractory overactive bladder (OAB) that has not adequately responded to medication therapy and we propose an appropriate care pathway to the treatment of OAB. We also attempt to address the cost of OAB treatments. Materials and Methods: A selective expert review of the current literature on the subject of refractory OAB using MEDLINE was performed and the data is summarized. We also review our experience in treating refractory OAB. The role and outcomes of various treatment options for refractory OAB are discussed and combined therapy with oral anticholinergics is explored. Emerging remedies including intravesical botulinum toxin injection and pudendal neuromodulation are also reviewed, along with conventional surgical options. Results: In general behavioral therapy, pelvic floor electrical stimulation, magnetic therapy and posterior tibial nerve stimulation (PTNS), have shown symptom decreases in 50-80% of patients with OAB. Depending on the study, combination therapy with oral anticholinergics seems to improve efficacy of behavioral therapy and PTNS in approximately 10-30%. In multicenter, long-term randomized controlled trials, sacral neuromodulation has been shown to improve symptoms of OAB and OAB incontinence in up to 80% of the patients treated. Studies involving emerging therapies such as pudendal serve stimulation suggest that there may be a 15-20% increase in efficacy over sacral neuromodulation, but long-term studies are not yet available. Another emerging therapy, botulinum toxin, is also showing similar success in reducing OAB symptoms in 80-90% of patients. Surgical approaches, such as bladder augmentation, are a last resort in the treatment of OAB and are rarely used at this point unless upper tract damage is a concern and all other treatment options have been exhausted. Conclusion: The vast majority of OAB patients can be managed successfully by behavioral options with or without anticholinergic medications. When those fail, neuromodulation or intravesical botulinum toxin therapies are successful alternatives for most of the remaining group. We encourage practitioners responsible for the care of OAB patients to gain experience with these options. More research is needed to assess the cost-effectiveness of various OAB treatments PMID:19675795

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yan, S; Broussard, G; De, K

Purpose: Recurrent chordomas are difficult to control locally. This dosimetric study investigates the feasibility of dose escalation to hypoxic regions, visualized on FMISO-PET, while respecting the dose constraints to the neighboring normal tissues/organs. We propose to deliver a higher dose to the areas of hypoxia (84.5Gy) using IMPT with the goal of improving local control. Methods: We currently have four patients with hypoxic subvolumes (HSV) greater than 10cc from the FMISO-PET image. The HSV was delineated based on the standardized uptake values of greater than 1.4 times of the muscle mean. Gross tumor volume (GTV) was delineated using planning CTmore » with the assistance of MRI fusion. The dose scheme is 50.4Gy RBE to CTV in 1.8Gy fractions, followed by an integrated boost of 27.0Gy RBE to GTV in 1.8Gy fractions and 34.5Gy RBE to HSV in 2.3Gy fractions. IMPT integrated boost plans were optimized with multi-criteria optimization (MCO). Posterior-anterior beam angles were used for these plans. We also propose using two posterior oblique fields to boost HSV to spare the skin folding. A medium spot size with 8mm to 15 mm (σ) in air at isocenter with energies from 220 MeV down to 90 MeV was used. Aperture was used for the medium spot size. A small spot size of 2.5 mm to 4.5 mm (σ) in air at isocenter with energies from 240 MeV down to 70 MeV was also proposed. Target coverage and dose to OARs were evaluated. Results: For the sacral chordoma patient that has been planned, the target homogeneity index is 3.2% for HSV, 55.9% for CTV and 11.9% for GTV. The max dose is 77GyRBE to rectum, 86.2GyRBE to sacral nerves and 73.9GyRBE to cauda equina. Conclusion: IMPT with integrated high dose boost to HSV determined from FMISO PET image is feasible. OAR dose constraints were met.« less

MAdCAM-1 expressing sacral lymph node in the lymphotoxin beta-deficient mouse provides a site for immune generation following vaginal herpes simplex virus-2 infection.

PubMed

Soderberg, Kelly A; Linehan, Melissa M; Ruddle, Nancy H; Iwasaki, Akiko

2004-08-01

The members of the lymphotoxin (LT) family of molecules play a critical role in lymphoid organogenesis. Whereas LT alpha-deficient mice lack all lymph nodes and Peyer's patches, mice deficient in LT beta retain mesenteric lymph nodes and cervical lymph nodes, suggesting that an LT beta-independent pathway exists for the generation of mucosal lymph nodes. In this study, we describe the presence of a lymph node in LT beta-deficient mice responsible for draining the genital mucosa. In the majority of LT beta-deficient mice, a lymph node was found near the iliac artery, slightly misplaced from the site of the sacral lymph node in wild-type mice. The sacral lymph node of the LT beta-deficient mice, as well as that of the wild-type mice, expressed the mucosal addressin cell adhesion molecule-1 similar to the mesenteric lymph node. Following intravaginal infection with HSV type 2, activated dendritic cells capable of stimulating a Th1 response were found in this sacral lymph node. Furthermore, normal HSV-2-specific IgG responses were generated in the LT beta-deficient mice following intravaginal HSV-2 infection even in the absence of the spleen. Therefore, an LT beta-independent pathway exists for the development of a lymph node associated with the genital mucosa, and such a lymph node serves to generate potent immune responses against viral challenge.

The dissimilar time course of temporary threshold shifts and reduction of inhibition in the inferior colliculus following intense sound exposure.

PubMed

Heeringa, A N; van Dijk, P

2014-06-01

Excessive noise exposure is known to produce an auditory threshold shift, which can be permanent or transient in nature. Recent studies showed that noise-induced temporary threshold shifts are associated with loss of synaptic connections to the inner hair cells and with cochlear nerve degeneration, which is reflected in a decreased amplitude of wave I of the auditory brainstem response (ABR). This suggests that, despite normal auditory thresholds, central auditory processing may be abnormal. We recorded changes in central auditory processing following a sound-induced temporary threshold shift. Anesthetized guinea pigs were exposed for 1 h to a pure tone of 11 kHz (124 dB sound pressure level). Hearing thresholds, amplitudes of ABR waves I and IV, and spontaneous and tone-evoked firing rates in the inferior colliculus (IC) were assessed immediately, one week, two weeks, and four weeks post exposure. Hearing thresholds were elevated immediately following overexposure, but recovered within one week. The amplitude of the ABR wave I was decreased in all sound-exposed animals for all test periods. In contrast, the ABR wave IV amplitude was only decreased immediately after overexposure and recovered within a week. The proportion of IC units that show inhibitory responses to pure tones decreased substantially up to two weeks after overexposure, especially when stimulated with high frequencies. The proportion of excitatory responses to low frequencies was increased. Spontaneous activity was unaffected by the overexposure. Despite rapid normalization of auditory thresholds, our results suggest an increased central gain following sound exposure and an abnormal balance between excitatory and inhibitory responses in the midbrain up to two weeks after overexposure. These findings may be associated with hyperacusis after a sound-induced temporary threshold shift. Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.

A case of Capnocytophaga canimorsus sacral abscess in an immunocompetent patient.

PubMed

Joswig, H; Gers, B; Dollenmaier, G; Heilbronner, R; Strahm, C

2015-04-01

We report a unique case of sacral Capnocytophaga canimorsus abscess successfully treated with surgery and antibiotics. Close contact to a dog was assumed to be the most likely source of infection. Established risk factors for invasive C. canimorsus infection such as splenectomy, alcoholism or overt immunosuppression could not be identified. The role of cigarette smoking, portal of entry and the possible relevance of altered skin microbiota as well as the diagnostic value of polymerase chain reaction are discussed in the light of the scarce literature of spinal C. canimorsus infections.

Robot-assisted radiofrequency ablation of a sacral S1-S2 aggressive hemangioma.

PubMed

Kaoudi, A; Capel, C; Chenin, L; Peltier, J; Lefranc, M

2018-05-16

Aggressive vertebral hemangiomas are rare tumors of the spine. The treatment management strategy usually consists of vertebroplasty, radiation therapy or in rare cases of surgical strategy. We present a case of a bulging sacral S1-S2 hemangioma in the spinal canal that could not be managed in the usual manner. Here, we demonstrate the usefulness of radiofrequency ablation technique as an alternative treatment as well as robotic assistance for optimal placement of the ablation probe within the lesion. Copyright © 2018. Published by Elsevier Inc.

Sentinel Lymph Node Biopsy for Cutaneous Head and Neck Melanoma: Mapping the Parotid Gland.

PubMed

Picon, Antonio I; Coit, Daniel G; Shaha, Ashok R; Brady, Mary S; Boyle, Jay O; Singh, Bhuvanesh B; Wong, Richard J; Busam, Klaus J; Shah, Jatin P; Kraus, Dennis H

2016-12-01

Sentinel lymph node biopsy (SLNB) for primary cutaneous head and neck melanoma (CHNM) has been shown to be successful and is the current standard of care for intermediate-thickness melanoma. We evaluated our experience with CHNM associated with SLNB mapping to the region of the parotid gland. Retrospective review of a prospectively collected melanoma database identified 1014 CHNMs. Two-hundred twenty-three patients underwent SLNB, and 72 (32%) had mapping in the region of the parotid gland between May 1995 and June 2003. The mean number of SLNs per patient was 2.5. A sentinel lymph node (SLN) was successfully identified in 94% of patients, and in 12%, the SLN was positive for metastatic disease. Biopsy of intraparotid SLNs was performed in 51.4% and of periparotid SLNs in 26.4%, and a superficial parotidectomy was performed in 22.2%. Ten patients were found to have lymph nodes in the parotid region with metastatic disease (eight identified by SLNB), and two (20%) patients developed intraparotid lymph node recurrence in the setting of a negative SLNB. Same-basin recurrence in SLN-negative patients was 3.3% with a median follow-up of 26 months. Facial nerve dysfunction was identified in seven (10%) patients. Facial nerve function returned to preoperative status in all patients. SLNB for patients with primary CHNM mapping to the parotid gland can be performed with a high degree of accuracy and a low morbidity consisting of temporary facial nerve paresis.

Blood lead concentration after a shotgun accident.

PubMed

Gerhardsson, Lars; Dahlin, Lars; Knebel, Richard; Schütz, Andrejs

2002-01-01

In an accidental shooting, a man in his late forties was hit in his left shoulder region by about 60 lead pellets from a shotgun. He had injuries to the vessels, the clavicle, muscles, and nerves, with total paralysis of the left arm due to axonal injury. After several surgical revisions and temporary cover with split skin, reconstructive surgery was carried out 54 days after the accident. The brachial plexus was swollen, but the continuity of the nerve trunks was not broken (no neuroma present). We determined the blood lead (BPb) concentration during a follow-up period of 12 months. The BPb concentration increased considerably during the first months. Although 30 lead pellets were removed during the reconstructive surgery, the BPb concentration continued to rise, and reached a peak of 62 microg/dL (3.0 micromol/L) on day 81. Thereafter it started to decline. Twelve months after the accident, BPb had leveled off at about 30 microg/dL. At that time, muscle and sensory functions had partially recovered. The BPb concentration exceeded 30 microg/dL for 9 months, which may have influenced the recovery rate of nerve function. Subjects with a large number of lead pellets or fragments embedded in the body after shooting accidents should be followed for many years by regular determinations of BPb. To obtain a more stable basis for risk assessment, the BPb concentrations should be corrected for variations in the subject's hemoglobin concentration or erythrocyte volume fraction.

Blood lead concentration after a shotgun accident.

PubMed Central

Gerhardsson, Lars; Dahlin, Lars; Knebel, Richard; Schütz, Andrejs

2002-01-01

In an accidental shooting, a man in his late forties was hit in his left shoulder region by about 60 lead pellets from a shotgun. He had injuries to the vessels, the clavicle, muscles, and nerves, with total paralysis of the left arm due to axonal injury. After several surgical revisions and temporary cover with split skin, reconstructive surgery was carried out 54 days after the accident. The brachial plexus was swollen, but the continuity of the nerve trunks was not broken (no neuroma present). We determined the blood lead (BPb) concentration during a follow-up period of 12 months. The BPb concentration increased considerably during the first months. Although 30 lead pellets were removed during the reconstructive surgery, the BPb concentration continued to rise, and reached a peak of 62 microg/dL (3.0 micromol/L) on day 81. Thereafter it started to decline. Twelve months after the accident, BPb had leveled off at about 30 microg/dL. At that time, muscle and sensory functions had partially recovered. The BPb concentration exceeded 30 microg/dL for 9 months, which may have influenced the recovery rate of nerve function. Subjects with a large number of lead pellets or fragments embedded in the body after shooting accidents should be followed for many years by regular determinations of BPb. To obtain a more stable basis for risk assessment, the BPb concentrations should be corrected for variations in the subject's hemoglobin concentration or erythrocyte volume fraction. PMID:11781173

Management of hyperfunctioning single thyroid nodules in the era of minimally invasive thyroid surgery.

PubMed

Tan, Charles; Sidhu, Stan; Sywak, Mark; Delbridge, Leigh

2009-05-01

Both surgical excision and radioiodine ablation are effective modalities in the management of hyperfunctioning thyroid nodules. Minimally invasive thyroid surgery (MITS) using the lateral mini-incision approach has previously been demonstrated to be a safe and effective technique for thyroid lobectomy. As such MITS may offer advantages as a surgical approach to hyperfunctioning thyroid nodules without the need for a long cervical incision or extensive dissection associated with formal open hemithyroidectomy. The aim of the present study was to assess the safety and efficacy of MITS for the treatment of hyperfunctioning thyroid nodules. This is a retrospective case study. Data were obtained from the University of Sydney Endocrine Surgical Unit Database from 2002 to 2007. There were 86 cases of hyperfunctioning thyroid nodules surgically removed during the study period, of which 10 (12%) were managed using the MITS approach. The ipsilateral recurrent laryngeal nerve was identified and preserved in all cases with no incidence of temporary or permanent nerve palsy. The external branch of the superior laryngeal nerve was visualized and preserved in eight cases (80%). There were no cases of postoperative bleeding. There was one clinically significant follicular thyroid carcinoma in the series (10%). In nine of 10 cases (90%) normalization of thyroid function followed surgery. MITS is a safe and effective procedure, achieving the benefits of a minimally invasive procedure with minimal morbidity. As such it now presents an attractive alternative to radioiodine ablation for the management of small hyperfunctioning thyroid nodules.

Sacral Bone Mass Distribution Assessed by Averaged Three-Dimensional CT Models: Implications for Pathogenesis and Treatment of Fragility Fractures of the Sacrum.

PubMed

Wagner, Daniel; Kamer, Lukas; Sawaguchi, Takeshi; Richards, R Geoff; Noser, Hansrudi; Rommens, Pol M

2016-04-06

Fragility fractures of the sacrum are increasing in prevalence due to osteoporosis and epidemiological changes and are challenging in their treatment. They exhibit specific fracture patterns with unilateral or bilateral fractures lateral to the sacral foramina, and sometimes an additional transverse fracture leads to spinopelvic dissociation. The goal of this study was to assess sacral bone mass distribution and corresponding changes with decreased general bone mass. Clinical computed tomography (CT) scans of intact pelves in ninety-one individuals (mean age and standard deviation, 61.5 ± 11.3 years) were used to generate three-dimensional (3D) models of the sacrum averaging bone mass in Hounsfield units (HU). Individuals with decreased general bone mass were identified by measuring bone mass in L5 (group 1 with <100 HU; in contrast to group 2 with ≥100 HU). In group 1, a large zone of negative Hounsfield units was located in the paraforaminal lateral region from S1 to S3. Along the trans-sacral corridors, a Hounsfield unit peak was observed laterally, corresponding to cortical bone of the auricular surface. The lowest Hounsfield unit values were found in the paraforaminal lateral region in the sacral ala. An intermediate level of bone mass was observed in the area of the vertebral bodies, which also demonstrated the largest difference between groups 1 and 2. Overall, the Hounsfield units were lower at S2 than S1. The models of averaged bone mass in the sacrum revealed a distinct 3D distribution pattern. The negative values in the paraforaminal lateral region may explain the specific fracture patterns in fragility fractures of the sacrum involving the lateral areas of the sacrum. Transverse fractures located between S1 and S2 leading to spinopelvic dissociation may occur because of decreased bone mass in S2. The largest difference between the studied groups was found in the vertebral bodies and might support the use of transsacral or cement-augmented implants. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

[CRITERION-RELATED VALIDITY OF SIT-AND-REACH TEST AS A MEASURE OF HAMSTRING EXTENSIBILITY IN OLDER WOMEN].

PubMed

López-Miñarro, Pedro Ángel; Vaquero-Cristóbal, Raquel; Muyor, José María; Espejo-Antúnez, Luis

2015-07-01

lumbo-sacral posture and the sit-andreach score have been proposed as measures of hamstring extensibility. However, the validity is influenced by sample characteristics. to determine the validity of lumbo-horizontal angle and score in the sit-and-reach test as measures of hamstring extensibility in older women. a hundred and twenty older women performed the straight leg raise test with both leg, and the sit-and-reach test (SR) in a random order. For the sitand- reach test, the score and the lumbo-sacral posture in bending (lumbo-horizontal angle, L-Hfx) were measured. the mean values of straight leg raise in left and right leg were 81.70 ± 13.83º and 82.10 ± 14.36º, respectively. The mean value of EPR of both legs was 81.90 ± 12.70º. The mean values of SR score and L-Hfx were -1.54 ± 8.09 cm and 91.08º ± 9.32º, respectively. The correlation values between the mean straight leg raise test with respect to lumbo-sacral posture and SR score were moderate (L-Hfx: r = -0.72, p < 0.01; SR: r = 0.70, p < 0.01). Both variables independently explained about 50% of the variance (L-Hfx: R2 = 0.52, p < 0,001; SR: R2 = 0.49, p < 0,001). the validity of lumbo-sacral posture in bending as measure of hamstring muscle extensibility on older women is moderate, with similar values than SR score. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

Does cortical bone thickness in the last sacral vertebra differ among tail types in primates?

PubMed

Nishimura, Abigail C; Russo, Gabrielle A

2017-04-01

The external morphology of the sacrum is demonstrably informative regarding tail type (i.e., tail presence/absence, length, and prehensility) in living and extinct primates. However, little research has focused on the relationship between tail type and internal sacral morphology, a potentially important source of functional information when fossil sacra are incomplete. Here, we determine if cortical bone cross-sectional thickness of the last sacral vertebral body differs among tail types in extant primates and can be used to reconstruct tail types in extinct primates. Cortical bone cross-sectional thickness in the last sacral vertebral body was measured from high-resolution CT scans belonging to 20 extant primate species (N = 72) assigned to tail type categories ("tailless," "nonprehensile short-tailed," "nonprehensile long-tailed," and "prehensile-tailed"). The extant dataset was then used to reconstruct the tail types for four extinct primate species. Tailless primates had significantly thinner cortical bone than tail-bearing primates. Nonprehensile short-tailed primates had significantly thinner cortical bone than nonprehensile long-tailed primates. Cortical bone cross-sectional thickness did not distinguish between prehensile-tailed and nonprehensile long-tailed taxa. Results are strongly influenced by phylogeny. Corroborating previous studies, Epipliopithecus vindobonensis was reconstructed as tailless, Archaeolemur edwardsi as long-tailed, Megaladapis grandidieri as nonprehensile short-tailed, and Palaeopropithecus kelyus as nonprehensile short-tailed or tailless. Results indicate that, in the context of phylogenetic clade, measures of cortical bone cross-sectional thickness can be used to allocate extinct primate species to tail type categories. © 2017 Wiley Periodicals, Inc.

Facial Nerve Injury and Other Complications Following Retromandibular Subparotid Approach for the Management of Condylar Fractures.

PubMed

Bruneau, Stéphane; Courvoisier, Delphine S; Scolozzi, Paolo

2018-04-01

To estimate the prevalence and identify risk factors for facial nerve paralysis (FNP) and other postoperative complications after the use of the retromandibular subparotid approach (RMSA) for the treatment of condylar fractures. Radiologic and clinical data from all patients who underwent an RMSA from 2007 through 2015 at the University Hospital of Geneva (Geneva, Switzerland) were retrospectively reviewed. The primary and secondary outcome variables were, respectively, FNP and other complications (unesthetic scars, infection, nonunion, malocclusion, salivary fistula, Frey syndrome, and loosening or breaking of plates and screws). Predictor variables included age, gender, mechanism of injury, delay from injury to surgery, surgeon's experience, location of fracture, side and pattern of fracture, concomitant facial fractures, and status of healing. Univariable logistic regression statistics were computed. Forty-eight subcondylar fractures in 43 consecutive patients were treated using the RMSA. Six fracture sites (12.5%) developed a temporary FNP that completely resolved within 4 months. Fractures at the neck level and with the comminution pattern were significant risk factors of postoperative FNP (P = .04 and P < .001, respectively; odds ratio = 82). Eight patients (18.6%) developed a slight transient malocclusion that was completely corrected within 3 to 4 weeks using guiding elastics and 1 patient (2.3%) had a wound dehiscence that resolved with a visible but thin and linear scar. The present study showed that 1) the FNP rate after the RMSA to surgery for condylar fractures was similar to that reported after the transparotid variant; 2) the FNP was transient and completely resolved in all patients; 3) neck and comminuted condylar fractures were statistically associated with increased risk of developing a postoperative temporary FNP; and 4) the final outcome was favorable with no major complications in any of the patients. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Multielectrode array recordings of bladder and perineal primary afferent activity from the sacral dorsal root ganglia

NASA Astrophysics Data System (ADS)

Bruns, Tim M.; Gaunt, Robert A.; Weber, Douglas J.

2011-10-01

The development of bladder and bowel neuroprostheses may benefit from the use of sensory feedback. We evaluated the use of high-density penetrating microelectrode arrays in sacral dorsal root ganglia (DRG) for recording bladder and perineal afferent activity. Arrays were inserted in S1 and S2 DRG in three anesthetized cats. Neural signals were recorded while the bladder volume was modulated and mechanical stimuli were applied to the perineal region. In two experiments, 48 units were observed that tracked bladder pressure with their firing rates (79% from S2). At least 50 additional units in each of the three experiments (274 total; 60% from S2) had a significant change in their firing rates during one or more perineal stimulation trials. This study shows the feasibility of obtaining bladder-state information and other feedback signals from the pelvic region with a sacral DRG electrode interface located in a single level. This natural source of feedback would be valuable for providing closed-loop control of bladder or other pelvic neuroprostheses.

Perforator-based island flap with a peripheral muscle patch for coverage of sacral sores.

PubMed

Chang, Jung Woo; Lee, Jang Hyun; Choi, Matthew Seung Suk

2016-06-01

Despite numerous therapeutic advances, the treatment of pressure sores remains a challenge. The increased use of perforator flaps enables surgeons to minimize donor-site morbidity by sparing the underlying muscle. In the presence of focal deep spaces, however, the inclusion of muscle would be beneficial. The goal of this study was to introduce a method for including a muscle patch at the periphery of a perforator-based island flap for coverage of sacral pressure sores. Between March 2010 and February 2015, 26 patients with stage IV sacral sores underwent perforator-based island flap reconstruction with a peripheral muscle patch. Patient characteristics, including sex, age, defect size, and postoperative complications, were recorded. All flaps survived without major complications. No flap necrosis was noted. The present study shows that a muscle patch incorporated into the periphery of a perforator-based flap can be transferred safely. This can be a good surgical option in cases where infection control or more volume is needed. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Herpes zoster-associated voiding dysfunction in hematopoietic malignancy patients.

PubMed

Imafuku, Shinichi; Takahara, Masakazu; Uenotsuchi, Takeshi; Iwato, Koji; Furue, Masutaka

2008-01-01

Voiding dysfunction is a rare but important complication of lumbo-sacral herpes zoster. Although the symptoms are transient, the clinical impact on immunocompromised patients cannot be overlooked. To clarify the time course of voiding dysfunction in herpes zoster, 13 herpes zoster patients with voiding dysfunction were retrospectively analyzed. Of 13 patients, 12 had background disease, and six of these were hematopoietic malignancies; four of these patients were hematopoietic stem cell transplant (HSCT) recipients. Ten patients had sacral lesions, two had lumbar, and one had thoracic lesions. Interestingly, patients with severe rash, or with hematopoietic malignancy had later onset of urinary retention than did patients with mild skin symptoms (Mann-Whitney U analysis, P = 0.053) or with other background disease (P = 0.0082). Patients with severe skin rash also had longer durations (P = 0.035). In one case, acute urinary retention occurred as late as 19 days after the onset of skin rash. In immune compromised subjects, attention should be paid to patients with herpes zoster in the lumbo-sacral area for late onset of acute urinary retention even after the resolution of skin symptoms.

Effective treatment of dyssynergic defecation using sacral neuromodulation in a patient with cerebral palsy.

PubMed

Chan, Daniel K; Barker, Matthew A

2015-01-01

Dyssynergic defecation is a complex bowel problem that leads to chronic constipation and abdominal pain. Management is often challenging owing to the incoordination of multiple pelvic floor muscles involved in normal defecation. We report a case of dyssynergic defecatory dysfunction in a patient with cerebral palsy treated with sacral neuromodulation. At presentation, Sitz marker study and magnetic resonance defecography showed evidence of chronic functional constipation. Anorectal manometry, rectal anal inhibitory reflex, and rectal sensation study showed intact reflex and decreased first sensation of lower canal at 50 mL. After stage 2 of InterStim implant placement, bowel habits improved to once- to twice-daily soft solid bowel movements from no regular solid bowel movements. Fecal incontinence improved from daily liquid and small solid loss to no stool leakage. In patients with systemic medical problems contributing to defecatory dysfunction and bowel incontinence, such as cerebral palsy, sacral neuromodulation was found to provide significant relief of bowel symptoms in addition to associated abdominal pain. As a result of intervention, the patient reported significant improvement in quality of life and less limitations due to dyssynergic defecation.

Office-based Electromyography-guided Botulinum Toxin Injection to the Cricopharyngeus Muscle: Optimal Patient Selection and Technique.

PubMed

Kim, Min-Su; Kim, Go-Woon; Rho, Young-Soo; Kwon, Kee-Hwan; Chung, Eun-Jae

2017-05-01

This retrospective study was carried out to investigate the effectiveness and safety of office-based electromyography-guided injection of botulinum toxin in the cricopharyngeus muscle of patients who did not show upper esophageal sphincter passage in a swallowing study in spite of maximal swallowing rehabilitation. Thirty-six patients who showed no or limited ability to oral feed after maximum swallowing rehabilitation were enrolled. Video fluoroscopic swallowing study, flexible endoscopic evaluation of swallowing, disability rating scale, penetration aspiration score, and National Institutes of Health swallowing safety scale were used in the evaluation of dysphagia. Success was defined as nondependence on gastrostomy for patients who previously were dependent on gastrostomy and improvement in disability rating scale score after botulinum toxin injections. The total success rate was 63.9%. The complication rate was very low, with only 1 patient showing temporary unilateral vocal fold paralysis. Botulinum toxin injection was more effective in patients with cranial nerve IX or X palsy than in those without it ( P = .006). This procedure can be a simple, safe, and effective tool in patients with cricopharyngeal dysfunction after swallowing rehabilitation, especially for cranial nerve IX or X palsy.

"Minimally invasive video-assisted thyroidectomy. Initial experience in a general surgery department".

PubMed

Dobrinja, Chiara; Trevisan, Giuliano; Liguori, Gennaro

2009-03-01

The aim of this study is to analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and demonstrate the feasibility of MIVAT also in non-referral centers. We report our initial experience based on a series of 47 patients selected for MIVAT at General Surgery Department of University of Trieste during a period from May 2005 to February 2007. The eligibility criteria were rigorously observed. Age, goiter volume, major diameter of the dominant nodule, operative times, pathologic findings, postoperative pain, length of hospital stay, cosmetic results, and complications were retrospectively analyzed. Thyroid lobectomy was successfully accomplished in 33 cases, total thyroidectomy in 14. Conversion to standard cervicotomy was required in three patients (6%). Mean operative time of lobectomy was 82.6 min and 118.7 for total thyroidectomy. Postoperative complications included 11 (23.4%) transient hypocalcemias, 2 (4.2%) hematomas, and 2 (4.2%) temporary laryngeal nerve palsies. None-recurrent nerve palsies was observed. The cosmetic result was excellent in most cases. Our experience demonstrates that MIVAT, after adequate training, is feasible and safe, with results comparable to conventional thyroidectomy, also in a General Surgery Department, from a dedicated team, with a sufficient and specific activity volume.

Lamina Cribrosa Changes after Laser In Situ Keratomileusis in Myopic Eyes

PubMed Central

Lee, Soomin; Choi, Da-Ye Diana; Lim, Dong Hui; Chung, Tae Young; Han, Jong Chul

2018-01-01

Purpose To determine deep optic nerve head structure changes after transient intraocular pressure elevation during laser in situ keratomileusis (LASIK) for myopia. Methods Enhanced depth imaging-optical coherence tomography was performed in each myopic eye that underwent LASIK surgery. Enhanced depth imaging-optical coherence tomography images were created at postoperative 1 day, 1 week, 2 weeks, and 1 month. Lamina cribrosa (LC) thickness, LC depth and prelaminar thickness at the superior, middle and inferior portions of the optic nerve head were measured by two investigators. Results Forty eyes in 40 patients were included in the present study. During follow-up, there were no significant differences in prelaminar thickness or LC depth. The LC demonstrated increased thickness at postoperative 1 day at all three locations (superior, middle, and inferior) (p < 0.001, p < 0.001, p < 0.001, respectively). However, no significant changes were observed at postoperative 1 week, 2 weeks, and 1 month. Conclusions The LC thickness could increase at 1 day after LASIK surgery. However, the thickness will gradually return to baseline morphology. Temporary intraocular pressure increase during LASIK does not appear to induce irreversible LC thickness changes. PMID:29611373

Lamina Cribrosa Changes after Laser In Situ Keratomileusis in Myopic Eyes.

PubMed

Lee, Soomin; Choi, Da Ye Diana; Lim, Dong Hui; Chung, Tae Young; Han, Jong Chul; Kee, Changwon

2018-04-01

To determine deep optic nerve head structure changes after transient intraocular pressure elevation during laser in situ keratomileusis (LASIK) for myopia. Enhanced depth imaging-optical coherence tomography was performed in each myopic eye that underwent LASIK surgery. Enhanced depth imaging-optical coherence tomography images were created at postoperative 1 day, 1 week, 2 weeks, and 1 month. Lamina cribrosa (LC) thickness, LC depth and prelaminar thickness at the superior, middle and inferior portions of the optic nerve head were measured by two investigators. Forty eyes in 40 patients were included in the present study. During follow-up, there were no significant differences in prelaminar thickness or LC depth. The LC demonstrated increased thickness at postoperative 1 day at all three locations (superior, middle, and inferior) (p < 0.001, p < 0.001, p < 0.001, respectively). However, no significant changes were observed at postoperative 1 week, 2 weeks, and 1 month. The LC thickness could increase at 1 day after LASIK surgery. However, the thickness will gradually return to baseline morphology. Temporary intraocular pressure increase during LASIK does not appear to induce irreversible LC thickness changes. © 2018 The Korean Ophthalmological Society.

Temporary morphological changes in plus disease induced during contact digital imaging

PubMed Central

Zepeda-Romero, L C; Martinez-Perez, M E; Ruiz-Velasco, S; Ramirez-Ortiz, M A; Gutierrez-Padilla, J A

2011-01-01

Objective To compare and quantify the retinal vascular changes induced by non-intentional pressure contact by digital handheld camera during retinopathy of prematurity (ROP) imaging by means of a computer-based image analysis system, Retinal Image multiScale Analysis. Methods A set of 10 wide-angle retinal pairs of photographs per patient, who underwent routine ROP examinations, was measured. Vascular trees were matched between ‘compression artifact' (absence of the vascular column at the optic nerve) and ‘not compression artifact' conditions. Parameters were analyzed using a two-level linear model for each individual parameter for arterioles and venules separately: integrated curvature (IC), diameter (d), and tortuosity index (TI). Results Images affected with compression artifact showed significant vascular d (P<0.01) changes in both arteries and veins, as well as in artery IC (P<0.05). Vascular TI remained unchanged in both groups. Conclusions Non-adverted corneal pressure with the RetCam lens could compress and decrease intra-arterial diameter or even collapse retinal vessels. Careful attention to technique is essential to avoid absence of the arterial blood column at the optic nerve head that is indicative of increased pressure during imaging. PMID:21760627

Effects of Low-frequency Current Sacral Dermatome Stimulation on Idiopathic Slow Transit Constipation

PubMed Central

Kim, Jin-Seop; Yi, Seung-Ju

2014-01-01

[Purpose] This study aimed to determine whether low-frequency current therapy can be used to reduce the symptoms of idiopathic slow transit constipation (ISTC). [Subjects] Fifteen patients (ten male and five female) with idiopathic slow transit constipation were enrolled in the present study. [Results] Bowel movements per day, bowel movements per week, and constipation assessment scale scores significantly improved after low-frequency current simulation of S2-S3. [Conclusion] Our results show that stimulation with low-frequency current of the sacral dermatomes may offer therapeutic benefits for a subject of patients with ISTC. PMID:25013277

Effects of Low-frequency Current Sacral Dermatome Stimulation on Idiopathic Slow Transit Constipation.

PubMed

Kim, Jin-Seop; Yi, Seung-Ju

2014-06-01

[Purpose] This study aimed to determine whether low-frequency current therapy can be used to reduce the symptoms of idiopathic slow transit constipation (ISTC). [Subjects] Fifteen patients (ten male and five female) with idiopathic slow transit constipation were enrolled in the present study. [Results] Bowel movements per day, bowel movements per week, and constipation assessment scale scores significantly improved after low-frequency current simulation of S2-S3. [Conclusion] Our results show that stimulation with low-frequency current of the sacral dermatomes may offer therapeutic benefits for a subject of patients with ISTC.

Role of intraoperative radiotherapy in the treatment of sacral chordoma.

PubMed

Jullien-Petrelli, Ariel Christian; García-Sabrido, J L; Orue-Echebarria, M I; Lozano, P; Álvarez, A; Serrano, J; Calvo, F M; Calvo-Haro, J A; Lasso, J M; Asencio, J M

2018-04-01

Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. To date, there are no series available in literature combining surgery and intraoperative radiotherapy (IORT). The objective of this study was to report the experience of our center in the management of sacral chordoma combining radical resection with both external radiotherapy and IORT. This is a retrospective case series. The patient sample included 15 patients with sacral chordoma resected in our center from 1998 to 2015. The outcome measures were overall survival (OS), disease-free survival (DFS), and rates of local and distant recurrences. We retrospectively reviewed the records of all the patients with sacral chordoma resected in our center from 1998 to December 2015. Overall survival, DFS, and rates of local and distant recurrences were calculated. Results between patients treated with or without IORT were compared. A total of 15 patients were identified: 8 men and 7 women. The median age was 59 years (range 28-77). Intraoperative radiotherapy was applied in nine patients and six were treated with surgical resection without IORT. In 13 patients, we performed the treatment of the primary tumor, and in two patients, we performed the treatment of recurrence disease. A posterior approach was used in four patients. Wide surgical margins (zero residue) were achieved in six patients, marginal margins (microscopic residue) were achieved in seven patients, and there were no patients with intralesional (R2) margins. At a median follow-up of 38 months (range 11-209 months), the 5-year OS in the IORT group was 100% versus 53% in the group of non-IORT (p=.05). The median DFS in the IORT group was 85 months, and that in the non-IORT group was 41 months. In the group without IORT, two patients died and nobody died during the follow-up in the group treated with IORT. High-sacrectomy treated patients had a median survival of 41 months, and low-sacrectomy treated patients had a median survival of 90 months. Disease-free survival in patients without gluteal involvement was 100% at 5 years, and that in patients with gluteal involvement was 40%. All patients with a recurrence in our study had gluteal involvement. Multidisciplinary management of sacral chordoma seems to improve local control. The use of IORT, in our experience, is associated with an increase in OS and DFS. The level of resection and gluteal involvement seems to affect survival. The posterior approach is useful in selected cases. Multicenter studies should be performed to confirm the utility of IORT. Copyright © 2017 Elsevier Inc. All rights reserved.

Minimally invasive surgical treatment of Bertolotti's Syndrome: case report.

PubMed

Ugokwe, Kene T; Chen, Tsu-Lee; Klineberg, Eric; Steinmetz, Michael P

2008-05-01

This article aims to provide more insight into the presentation, diagnosis, and treatment of Bertolotti's syndrome, which is a rare spinal disorder that is very difficult to recognize and diagnose correctly. The syndrome was first described by Bertolotti in 1917 and affects approximately 4 to 8% of the population. It is characterized by an enlarged transverse process at the most caudal lumbar vertebra with a pseudoarticulation of the transverse process and the sacral ala. It tends to present with low back pain and may be confused with facet and sacroiliac joint disease. In this case report, we describe a 40-year-old man who presented with low back pain and was eventually diagnosed with Bertolotti's syndrome. The correct diagnosis was made based on imaging studies which included computed tomographic scans, plain x-rays, and magnetic resonance imaging scans. The patient experienced temporary relief when the abnormal pseudoarticulation was injected with a cocktail consisting of lidocaine and steroids. In order to minimize the trauma associated with surgical treatment, a minimally invasive approach was chosen to resect the anomalous transverse process with the accompanying pseudoarticulation. The patient did well postoperatively and had 97% resolution of his pain at 6 months after surgery. As with conventional surgical approaches, a complete knowledge of anatomy is required for minimally invasive spine surgery. This case is an example of the expanding utility of minimally invasive approaches in treating spinal disorders.

Transsacral Osseous Corridor Anatomy Is More Amenable To Screw Insertion In Males: A Biomorphometric Analysis of 280 Pelves.

PubMed

Gras, Florian; Gottschling, Heiko; Schröder, Manuel; Marintschev, Ivan; Hofmann, Gunther O; Burgkart, Rainer

2016-10-01

Percutaneous iliosacral screw placement is the standard procedure for fixation of posterior pelvic ring lesions, although a transsacral screw path is being used more frequently in recent years owing to increased fracture-fixation strength and better ability to fix central and bilateral sacral fractures. However, biomorphometric data for the osseous corridors are limited. Because placement of these screws in a safe and effective manner is crucial to using transsacral screws, we sought to address precise sacral anatomy in more detail to look for anatomic variation in the general population. We asked: (1) What proportion of healthy pelvis specimens have no transsacral corridor at the level of the S1 vertebra owing to sacral dysmorphism? (2) If there is no safe diameter for screw placement in the transsacral S1 corridor, is an increased and thus safe diameter of the transsacral S2 corridor expected? (3) Are there sex-specific differences in sacral anatomy and are these correlated with known anthropometric parameters? CT scans of pelves of 280 healthy patients acquired exclusively for medical indications such as polytrauma (20%), CT angiography (70%), and other reasons (10%), were segmented manually. Using an advanced CT-based image analysis system, the mean shape of all segmented pelves was generated and functioned as a template. On this template, the cylindric transsacral osseous corridor at the level of the S1 and S2 vertebrae was determined manually. Each pelvis then was registered to the template using a free-form registration algorithm to measure the maximum screw corridor diameters on each specimen semiautomatically. Thirty of 280 pelves (11%) had no transsacral S1 corridor owing to sacral dysmorphism. The average of maximum cylindrical diameters of the S1 corridor for the remaining 250 pelves was 12.8 mm (95% CI, 12.1-13.5 mm). A transverse corridor for S2 was found in 279 of 280 pelves, with an average of maximum cylindrical diameter of 11.6 mm (95% CI, 11.3-11.9 mm). Decreasing transsacral S1 corridor diameters are correlated with increasing transsacral S2 corridor diameters (R value for females, -0.260, p < 0.01; for males, -0.311, p < 0.001). Female specimens were more likely to have sacral dysmorphism (defined as a pelvis without a transsacral osseous corridor at the level of the S1 vertebra) than were male specimens (females, 16%; males, 7%; p < 0.003). Furthermore female pelves had smaller-corridor diameters than did male pelves (females versus males for S1: 11.7 mm [95% CI, 10.6-12.8 mm] versus 13.5 mm [95% CI, 12.6-14.4 mm], p < 0.01; and for S2: 10.6 mm [95% CI, 10.1-11.1 mm] versus 12.2 mm [95% CI, 11.8-12.6 mm ], p < 0.0001). Narrow corridors and highly individual, sex-dependent variance of morphologic features of the sacrum make transsacral implant placement technically demanding. Individual preoperative axial-slice CT scan analyses and orthogonal coronal and sagittal reformations are recommended to determine the prevalence of sufficient-sized osseous corridors on both levels for safe screw placements, especially in female patients, owing to their smaller corridor diameters and higher rate of sacral dysmorphism.

Transient neurologic deficit after spinal anesthesia: local anesthetic maldistribution with pencil point needles?

PubMed

Beardsley, D; Holman, S; Gantt, R; Robinson, R A; Lindsey, J; Bazaral, M; Stewart, S F; Stevens, R A

1995-08-01

Recent reports of transient neurologic deficits have raised concern about the potential toxicity of single-dose spinal 5% lidocaine in 7.5% dextrose. Two cases of volunteers who experienced minor local sensory deficits after slow (60 s) injections of 2 mL 5% lidocaine via Whitacre needles are described. One case was a result of a double injection because of a "failed" block. It seemed possible that the neurologic deficit in these cases resulted from neurotoxicity associated with maldistribution of local anesthetic. Using an in vitro spinal model, we investigated drug distribution resulting from injections through side-port spinal needles to determine whether the use of these needles could result in high local concentrations of hyperbaric solutions. A spinal canal model was fabricated using human magnetic resonance measurements. The model was placed in a surgical supine position and filled with lactated Ringer's solution to simulate the specific gravity of cerebral spinal fluid at 22 degrees C. A hyperbaric solution of phthalocyanine blue dye and dextrose (SG 1.042), simulating the anesthetic, was injected through three different needles (27-gauge 4 11/16-in. Whitacre, 25-gauge 3 1/2-in. Whitacre, 25-gauge 3 1/2-in. Quincke). Triplicate injections were done at rapid (2 mL/10 s) and slow (2 mL/60 s) rates, with needle side ports oriented in a sacral and cephalad direction. At slow rates of injection, using 27- or 25-gauge sacrally directed Whitacre needles, injections showed evidence of maldistribution with extrapolated peak sacral lidocaine concentrations reaching 2.0%. In contrast, distribution after slow injection through sacrally directed Quincke needles was uniform.(ABSTRACT TRUNCATED AT 250 WORDS)

Sacroplasty procedural extravasation with high viscosity bone cement: comparing the intraoperative long-axis versus short-axis techniques in osteoporotic cadavers.

PubMed

Miller, Jeffrey W; Diani, Art; Docsa, Steve; Ashton, Kristi; Sciamanna, Michele

2017-09-01

Percutaneous sacroplasty involves image-guided injection of bone cement for sacral insufficiency fractures to alleviate pain and facilitate mobility. Correct sacral placement of the cement and the risk of cement extravasation present procedural challenges. This study compares the occurrence, number, location, and surface area of high viscosity radiopaque bone cement extravasation via biplane fluoroscopy with Dyna CT between the fluoroscopically-guided intraoperative long-axis and short-axis sacroplasty techniques in osteoporotic cadavers. Ten osteoporotic cadavers underwent bilateral percutaneous instillation of VertaPlex HV High Viscosity Radiopaque Bone Cement. Long- and short-axis sacroplasty techniques were randomly assigned to zone 1 of the left or right sacral ala of each cadaver. Cement extravasation data were summarized by technique (long-axis vs short-axis) and time period (15-min and 3-hour post-procedure syngo DynaCT scan) in the form of point and CI estimates for the true proportions of cement extravasation. No procedural sacral extravasation differences were observed between the long-axis and short-axis sacroplasty techniques. There were no occurrences of intra-procedural or post-procedural cement extravasation at 15 min or 3 hours in association with either the long-axis sacroplasty technique or the short-axis sacroplasty technique. The long- and short-axis sacroplasty techniques, using high viscosity cement with careful post-procedural positioning, result in no occurrence of cement extravasation in porous osteoporotic cadaver bone. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Screw Loosening and Pelvic Canal Narrowing After Lateral Plating of Feline Ilial Fractures With Locking and Nonlocking Plates.

PubMed

Schmierer, Philipp A; Kircher, Patrick R; Hartnack, Sonja; Knell, Sebastian C

2015-10-01

To compare the frequency of complications, including screw loosening and pelvic canal narrowing, associated with dynamic compression plating, locking plating, and double locking plating of ilial fractures in cats. Historical cohort study. The radiographs and medical records of cats with pelvic fractures that were presented between 2004 and 2013 were reviewed. The cases were categorized based on the plate type and number as dynamic compression plate (DCP), single locking plate (LPS) and double locking plates (dLPS). The frequency of screw loosening was compared across categories using a Fisher's exact test. The change in pelvic alignment, described by the change in sacral index (postoperative sacral index-followup sacral index), was compared across plate categories using ANOVA. The frequency of screw loosening for DCP (5/10) was significantly higher than LPS (1/13) and dLPS (0/11) (P = .05, P = .012, respectively). There was no significant difference in the SI change across plate categories. The mean change in sacral index for DCP was -0.11 (95%CI -0.25 to 0.03), for LPS was 0.0007 (95%CI -0.07 to 0.08), and for dLPS was -0.01 (95%CI -0.04 to 0.02). None of the cats showed constipation postoperatively. Screw loosening occurred less often but the change in pelvic canal alignment was not significantly different in ilial fractures repaired with LPS or dLPS compared to ilial fractures repaired with DCP. Locking plating of ilial fractures in cats may offer advantages compared to nonlocking plating. © Copyright 2015 by The American College of Veterinary Surgeons.

How Did the Pelvis and Vertebral Column Become a Functional Unit during the Transition from Occasional to Permanent Bipedalism?

PubMed

Tardieu, Christine; Hasegawa, Kazuhiro; Haeusler, Martin

2017-05-01

The functional linkage between pelvis and spine remained long hidden to science. Here, we recount the history of research that led in 1992 to the discovery of the "angle of sacral incidence" by the team of G. Duval-Beaupère. This angle, formed between a ray from the hip joint center to the superior sacral surface and the perpendicular to the sacral surface, was later called pelvic incidence. Specific to each individual, pelvic incidence is tightly correlated with the degree of lumbar lordosis. It is each individual's "signature" for an efficient sagittal balance since it represents the sum of two positional parameters, sacral slope and pelvic tilt. The simultaneous experimental determination of the trunk line of gravity permitted Duval-Beaupère's team to elucidate the conditions of an efficient sagittal balance of the trunk on the lower limbs. We present an in vivo EOS study of eight spino-pelvic parameters describing the sagittal balance in 131 adults. We observe a chain of correlations between the six angular parameters and discuss the functional significance of these results. We show that pelvic incidence increases and lumbar lordosis develops when the infant learns to walk, leading to a correlation between these parameters. This process of association between pelvis and spine might have acquired a solid genetic basis during hominid evolution by natural selection acting on both pelvis and spine. We suggest that this process of functional integration was only possible in the context of bipedal locomotion becoming permanent and stereotyped, expressed by a relatively invariant, periodic walking cycle. Anat Rec, 300:912-931, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Sacral chordomas: Impact of high-dose proton/photon-beam radiation therapy combined with or without surgery for primary versus recurrent tumor

DOE Office of Scientific and Technical Information (OSTI.GOV)

Park, Lily; De Laney, Thomas F.; Liebsch, Norbert J.

2006-08-01

Purpose: To assess the efficacy of definitive treatment of sacral chordoma by high-dose proton/photon-beam radiation therapy alone or combined with surgery. Methods and Materials: The records of 16 primary and 11 recurrent sacral chordoma patients treated from November 1982 to November 2002 by proton/photon radiation therapy alone (6 patients) or combined with surgery (21 patients) have been analyzed for local control, survival, and treatment-related morbidity. The outcome analysis is based on follow-up information as of 2005. Results: Outcome results show a large difference in local failure rate between patients treated for primary and recurrent chordomas. Local control results by surgerymore » and radiation were 12/14 vs. 1/7 for primary and recurrent lesions. For margin-positive patients, local control results were 10 of 11 and 0 of 5 in the primary and recurrent groups, respectively; the mean follow-up on these locally controlled patients was 8.8 years (4 at 10.3, 12.8, 17, and 21 years). Radiation alone was used in 6 patients, 4 of whom received {>=}73.0 Gy (E); local control was observed in 3 of these 4 patients for 2.9, 4.9, and 7.6 years. Conclusion: These data indicate a high local control rate for surgical and radiation treatment of primary (12 of 14) as distinct from recurrent (1 of 7) sacral chordomas. Three of 4 chordomas treated by {>=}73.0 Gy (E) of radiation alone had local control; 1 is at 91 months. This indicates that high-dose proton/photon therapy offers an effective treatment option.« less

Complications and troubleshooting of sacral neuromodulation therapy.

PubMed

Hijaz, Adonis; Vasavada, Sandip

2005-02-01

As evident from the authors' series, the complications of sacral neuromodulation have changed with the introduction of the tined lead and the placement of the generator over the back. In the earlier series, most complications were related to pain at the generator site, which was rare in the authors' series. The posterior location of the generator seems to be better tolerated than the anterior location, which could explain the rare need for revisions for pain at the generator site. Lead migration was observed in 8.4% of the original sacral neuromodulation study group series. This was seen rarely in the authors' series in either stage-one or stage-two revisions. As part of the routine work-up of patients who present with decreased function after a successful period response in stage two, the authors obtain a lateral radiograph of the sacrum; the authors have made the diagnosis of lead migration rarely (1/130; 0.6%). Spinelli and colleagues reported on the use of the tined lead in 15 patients, and observed no lead migration during either the screening period (average 38.8 days) or during follow-up of IPG implantation cases (average 11 months). The total infection rate in the whole series was 18/180 (10%), which was slightly higher than that reported by the sacral neuromodulation study group (6.1%). Revision rates for stage one and stage two were 12.2% and 20%, respectively. The revision rate in the original study group was 33.3%. Thus, with advancing technology, new problems may arise, but the implanting physician should be aware of the ways to evaluate and manage these complications and appropriately troubleshoot patients with suboptimal responses.

What's New in the Toolbox for Constipation and Fecal Incontinence?

PubMed

Lee, Yeong Yeh

2014-01-01

Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut-brain-microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.

Chemical hazard information profile of triphenyl phosphite

DOE Office of Scientific and Technical Information (OSTI.GOV)

Faust, R.A.; Wiedow, M.A.; Daugherty, M.W.

1986-12-01

The only human study located showed that triphenyl phosphite applied to the skin in a 1:3 dilution with cold cream for 48 h caused slight irritation, and challenge with the compound 14 days later produced a moderate sensitization reaction. The most significant health effects described in experimental animals are those affecting the nervous system. In adult rats, subacute exposure to the chemical produced gross ataxia and spinal cord neuropathy which predominantly affected the lateral and ventral columns of the lumber and sacral regions. Other symptoms included hyperexcitability and agitation after several days, muscle wasting, asymmetric gait, and hind-limb paralysis. Allmore » animals developed tail rigidity with a kinky appearance, and some animals displayed a circling behavior. The compound appeared to only weakly inhibit acetylcholinesterase activity. Single oral doses of triphenyl phosphite Gallus domesticus produced ataxia, and spinal cord and peripheral nerve histopathology. Neurotoxicity in rats, cats, and chickens indicated that triphenyl phosphite caused two distinct stages of action. Rats given s.c. injections of the chemical exhibit rapidly-developing stage or fine or coarse tremors which disappeared after a few hours. The later stage, occurring several days after treatment, caused hyperexcitability, spasticity and incoordination, followed by partial flaccid paralysis of the extremities. 135 refs., 2 tabs.« less

Medical devices of the head, neck, and spine.

PubMed

Hunter, Tim B; Yoshino, Mark T; Dzioba, Robert B; Light, Rick A; Berger, William G

2004-01-01

There are many medical devices used for head, neck, and spinal diseases and injuries, and new devices are constantly being introduced. Many of the newest devices are variations on a previous theme. Knowing the specific name of a device is not important. It is important to recognize the presence of a device and to have an understanding of its function as well as to be able to recognize the complications associated with its use. The article discusses the most common and important devices of the head, neck, and spine, including cerebrospinal fluid shunts and the Codman Hakim programmable valve; subdural drainage catheters, subdural electrodes, intracranial electrodes, deep brain stimulators, and cerebellar electrodes; coils, balloons, adhesives, particles, and aneurysm clips; radiation therapy catheters, intracranial balloons for drug installation, and carmustine wafers; hearing aids, cochlear implants, and ossicular reconstruction prostheses; orbital prostheses, intraocular silicone oil, and lacrimal duct stents; anterior and posterior cervical plates, posterior cervical spine wiring, odontoid fracture fixation devices, cervical collars and halo vests; thoracic and lumbar spine implants, anterior and posterior instrumentation for the thoracic and lumbar spine, vertebroplasty, and artificial disks; spinal column stimulators, bone stimulators, intrathecal drug delivery pumps, and sacral stimulators; dental and facial implant devices; gastric and tracheal tubes; vagus nerve stimulators; lumboperitoneal shunts; and temperature- and oxygen-sensing probes. Copyright RSNA, 2004

Neural Mechanisms Underlying Lower Urinary Tract Dysfunction

PubMed Central

Ogawa, Teruyuki; Miyazato, Minoru; Kitta, Takeya; Furuta, Akira; Chancellor, Michael B.; Tyagi, Pradeep

2014-01-01

This article summarizes anatomical, neurophysiological, and pharmacological studies in humans and animals to provide insights into the neural circuitry and neurotransmitter mechanisms controlling the lower urinary tract and alterations in these mechanisms in lower urinary tract dysfunction. The functions of the lower urinary tract, to store and periodically release urine, are dependent on the activity of smooth and striated muscles in the bladder, urethra, and external urethral sphincter. During urine storage, the outlet is closed and the bladder smooth muscle is quiescent. When bladder volume reaches the micturition threshold, activation of a micturition center in the dorsolateral pons (the pontine micturition center) induces a bladder contraction and a reciprocal relaxation of the urethra, leading to bladder emptying. During voiding, sacral parasympathetic (pelvic) nerves provide an excitatory input (cholinergic and purinergic) to the bladder and inhibitory input (nitrergic) to the urethra. These peripheral systems are integrated by excitatory and inhibitory regulation at the levels of the spinal cord and the brain. Therefore, injury or diseases of the nervous system, as well as disorders of the peripheral organs, can produce lower urinary tract dysfunction, leading to lower urinary tract symptoms, including both storage and voiding symptoms, and pelvic pain. Neuroplasticity underlying pathological changes in lower urinary tract function is discussed. PMID:24578802

The Other Bladder Syndrome: Underactive Bladder

PubMed Central

Miyazato, Minoru; Yoshimura, Naoki; Chancellor, Michael B

2013-01-01

Detrusor underactivity, or underactive bladder (UAB), is defined as a contraction of reduced strength and/or duration resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. UAB can be observed in many neurologic conditions and myogenic failure. Diabetic cystopathy is the most important and inevitable disease developing from UAB, and can occur silently and early in the disease course. Careful neurologic and urodynamic examinations are necessary for the diagnosis of UAB. Proper management is focused on prevention of upper tract damage, avoidance of overdistension, and reduction of residual urine. Scheduled voiding, double voiding, al-blockers, and intermittent self-catheterization are the typical conservative treatment options. Sacral nerve stimulation may be an effective treatment option for UAB. New concepts such as stem cell therapy and neurotrophic gene therapy are being explored. Other new agents for UAB that act on prostaglandin E2 and EP2 receptors are currently under development. The pharmaceutical and biotechnology industries that have a pipeline in urology and women’s health may want to consider UAB as a potential target condition. Scientific counsel and review of the current pharmaceutical portfolio may uncover agents, including those in other therapeutic fields, that may benefit the management of UAB. PMID:23671401

Evaluation of surgical treatment in mandibular condyle fractures.

PubMed

Vesnaver, Aleš; Ahčan, Uroš; Rozman, Janez

2012-12-01

In the past, fractures of the mandibular condylar process were, as a rule, treated conservatively. At the Department of Maxillofacial and Oral Surgery of the University Medical Centre Ljubljana, Slovenia, our doctrine was changed in 2002 on the basis of preliminary results and reports in the literature, and these fractures were started to be treated surgically by open reduction and internal fixation with miniplates and screws, which led to good results and a shorter rehabilitation period. The goal of this study was to determine the safety and efficiency of surgical treatment, as well as to compare long-term results of surgical and conservative treatment, as objectively as possible. Two groups of patients, which had all sustained a unilateral, extra-articular mandibular condyle fracture, were compared. In the test group, there were 42 surgically treated patients, and in the control group, 20 conservatively treated patients. Clinical parameters and X-ray images were assessed in both groups and compared by the two tailed Student t test, and in case of attributive variables by the χ(2) test. Within the surgically treated group, postoperative and intraoperative complications were noted: temporary facial nerve palsy, development of a parotid salivary fistula, disturbance of auricle sensibility due to injury of the greater auricular nerve, miniplate fracture, as well as intraoperative bleeding, postoperative haematoma formation, infection, reoperation due to fragment malposition and other complications. Postoperative scars were also assessed. Statistically significant differences between the surgically and conservatively treated patients were found when comparing clinical parameters as well as X-ray images, the results being better in the surgically treated group. Complications of surgical treatment were also noted, the most important among them temporary paresis of facial nerve branches, which occurred in 10 patients (24%). Plate fractures occurred in five patients (12%), in four of them miniplates of sizes less than 2.0mm were used. There were no cases of significant intraoperative bleeding, two cases (5%) required drainage of postoperative haematomas, and one patient (2%) experienced a mild postoperative infection, which was easily controlled with amoxicillin with clavulanic acid. The scar was hidden best if a facelift incision was used, and a hypertrophic scar developed in only one patient (2%). Results of surgical treatment of condylar process fractures are superior to the results of conservative treatment, and the procedure is safe with the transparotid surgical approach and adequate surgical technique. Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Temporary Medial Upper Eyelid Lagophthalmos after External Dacryocystorhinostomy.

PubMed

Haefliger, I O; Meienberg, O; Pimentel de Figueiredo, A R

2016-04-01

Background. Report of three cases of medial upper eyelid lagophthalmos as complication of external dacryocystorhinostomy. History and Signs. Shortly after dacryocystorhinostomy (skin incision on the side of the nose), three of ten consecutive patients (28 ± 4 years; mean ± standard deviation), presented with an ipsilateral lagophthalmos of 4 ± 1 mm in voluntary eyelid closure and 6 ± 1 mm in spontaneous blink. The lagophthalmos was due to a selective paresis of the medial part of the orbicularis oculi muscle of the upper eyelid. Patient 1 complained bitterly of dry eye symptoms and of her lagophthalmos. Patient 2 had mild symptoms but became very concerned after peers made her aware of her asymmetric blink. Patient 3 was asymptomatic and did not notice anything particular. Therapy and Outcome. Lagophthalmos resolved spontaneously within three months after surgery, first by improvement of voluntary eyelid closure and then of spontaneous blinking. Conclusions. Temporary lagophthalmos can occur as a complication of external dacryocystorhinostomy, most likely due to damage of the (only recently described) superficial buccal and/or zygomatic branches of the facial nerve that run upward to cross over the medial ligament and innervate the medial part of the orbicularis oculi muscle. Georg Thieme Verlag KG Stuttgart · New York.

[Semiotics of the Currarino syndrome].

PubMed

Pankevych, T L; Lóniushkin, O I; Sitkovskyĭ, M B; Kaplan, V M; Iurchenko, M I; Cherniienko, Iu L

1993-01-01

The main criteria for diagnosis of the Currarino syndrome have been defined. Roentgenologic investigation of the lumbar-sacral spine in direct projection is indicated to all the patients with anorectal developmental defects, in particular with congenital anorectal stenosis. In detection of a specific defect of the terminal vertebrae, the performance of computed tomography of the pelvic bottom and nuclear magnetic resonance tomography of the lumbar-sacral spine is necessary. This permits to assess the nature of a presacral tumour and degree of dysplasia of the external and sphincter. Timely diagnosis of the Currarino syndrome in children with the anorectal developmental defects permits to avoid severe septic and functional complications in surgical intervention.

Sacral herpes-zoster infection presenting as sciatic pain.

PubMed

Ablin, J; Symon, Z; Mevorach, D

1996-06-01

Acute herpes-zoster infection is a painful dermatomal lesion that can be manifested by a wide array of neurologic symptoms. We present a 55-year-old female with non-Hodgkin's lymphoma, who developed a left sciatic pain involving the S roots. Two weeks later, the patient developed fever and vesicular rash over the left gluteal area. Herpes-zoster infection was diagnosed and confirmed by the presence of immunoglobulin M (IgM) antibodies against varicella-zoster. The pain and rash resolved, after treatment with acyclovir. In the appropriate clinical setting, sacral herpes-zoster infection ought to be considered in the differential diagnosis of new-onset sciatic pain.

Distribution of herpes simplex virus types 1 and 2 genomes in human spinal ganglia studied by PCR and in situ hybridization.

PubMed

Obara, Y; Furuta, Y; Takasu, T; Suzuki, S; Suzuki, H; Matsukawa, S; Fujioka, Y; Takahashi, H; Kurata, T; Nagashima, K

1997-06-01

Clinical data indicate that the recurring herpes simplex virus (HSV) from oro-labial lesions is HSV subtype 1 and that the virus from genital lesions is HSV-2. This suggests that HSV-1 and HSV-2 reside in latent forms in the trigeminal ganglia and sacral ganglia, respectively. However, the distribution of latent HSV-1 and HSV-2 infections in human spinal ganglia has not been fully examined. This report concerns the application of polymerase chain reaction (PCR) and in situ hybridization (ISH) to such a study. By using PCR and employing the respective primers, HSV-1 and HSV-2 DNAs were detected in 207 of 524 samples from 262 spinal ganglia (from the cervical to the sacral ganglia) examined on both sides. The percentages of HSV-1 and HSV-2 detected in a given set of ganglia were similar, indicating an absence of site preference. By ISH, few but positive hybridization signals were detected evenly in sacral ganglia sections. The data suggest that regional specificity of recurrent HSV infections is not due to regional distribution of latent virus, but that local host factors may be important for recurrences.

Giant cell tumor of the spine.

PubMed

Ozaki, Toshifumi; Liljenqvist, Ulf; Halm, Henry; Hillmann, Axel; Gosheger, Georg; Winkelmann, Winfried

2002-08-01

Six patients with giant cell tumor of the spine had surgery between 1981 and 1995. Three lesions were located in the scrum, two lesions were in the thoracic spine, and one lesion was in the lumbar spine. Preoperatively, all patients had local pain and neurologic symptoms. Two patients had cement implanted after curettage or intralesional excision of the sacral tumor; one patient had a local relapse. After the second curettage and cement implantation, the tumor was controlled. One patient with a sacral lesion had marginal excision and spondylodesis; no relapse developed. Two patients with thoracic lesions had planned marginal excision and spondylodesis; the margins finally became intralesional, but no relapse developed. One patient with a lumbar lesion had incomplete removal of the tumor and received postoperative irradiation. At the final followup (median, 69 months), five of six patients were disease-free and one patient died of disease progression. Two of the five surviving patients had pain after standing or neurologic problems. Although some contamination occurred, planning a marginal excision of the lesion seems beneficial for vertebral lesions above the sacrum. Total sacrectomy of a sacral lesion seems to be too invasive when cement implantation can control the lesion.

En bloc sacrectomy and reconstruction: technique modification for pelvic fixation.

PubMed

Newman, C Benjamin; Keshavarzi, Sassan; Aryan, Henry E

2009-12-01

When the management of sacral tumors requires partial or complete sacrectomy, the spinopelvic apparatus must be reconstructed. This is a challenging and infrequently performed operation, and as such, many spine surgeons are unfamiliar with techniques available to carry out these procedures. A 34-year-old man presented with severe low back pain, mild left ankle dorsiflexion weakness, and left S1 paresthesias. Imaging revealed a large sacral mass extending into the L5/S1 and S1/S2 neural foramina as well as the presacral visceral and vascular structures. Needle biopsy of this mass demonstrated a low-grade chondrosarcoma. A 2-stage anterior/posterior en bloc sacrectomy with a novel modification of the Galveston L-rod pelvic ring reconstruction was carried out. Our modification takes advantage of new materials and implant technology to offer another alternative in reconstruction of the spinopelvic junction. Understanding the anatomy and biomechanics of the spinopelvic apparatus and the lumbosacral junction, as well as having a familiarity with the various techniques available for carrying out sacrectomy and pelvic ring reconstruction, will enable the spine surgeon to effectively manage sacral tumors. Copyright 2009 Elsevier Inc. All rights reserved.

Feasibility of Using Ultrasonography to Establish Relationships Among Sacral Base Position, Sacral Sulcus Depth, Body Mass Index, and Sex.

PubMed

Lockwood, Michael D; Kondrashova, Tatyana; Johnson, Jane C

2015-11-01

Identifying relationships among anatomical structures is key in diagnosing somatic dysfunction. Ultrasonography can be used to visualize anatomical structures, identify sacroiliac landmarks, and validate anatomical findings and measurements in relation to somatic dysfunction. As part of the osteopathic manipulative medicine course at A.T. Still University-Kirksville College of Osteopathic Medicine, first-year students are trained to use ultrasonography to establish relationships among musculoskeletal structures. To determine the ability of first-year osteopathic medical students to establish sacral base position (SBP) and sacral sulcus depth (SSD) using ultrasonography and to identify the relationship of SBP and SSD to body mass index (BMI) and sex. Students used ultrasonography to obtain the distance between the skin and the sacral base (the SBP) and the distance between the skin and the tip of the posterior superior iliac spine bilaterally. Next, students calculated the SSD (the distance between the tip of the posterior superior iliac spine and the SBP). Data were analyzed with respect to side of the body, BMI, sex, and age. The BMI data were subdivided into normal (18-25 mg/kg) and overweight (25-30 mg/kg) groups. Ultrasound images of 211 students were included in the study. The SBP was not significantly different between the left and right sides (36.5 mm vs 36.5 mm; P=.95) but was significantly different between normal and overweight BMI categories (33.0 mm vs 40.0 mm; P<.001) and between men and women (34.1 mm vs 39.0 mm; P<.001). The SSD was not significantly different between left and right sides (18.9 mm vs 19.8 mm; P=.08), normal and overweight BMI categories (18.9 mm vs 19.7 mm, P=.21), or men and women (19.7 mm vs 19.0 mm; P=.24). No significant relationship was identified between age and SBP (P=.46) or SSD (P=.39); however, the age range was narrow (21-33 years). The study yielded repeatable and reproducible results when establishing SBP and SSD using ultrasonography. The statistically significant relationship between SBP and higher BMI and between SBP and female sex may point to more soft tissue overlaying the sacrum in these groups. Further research is needed on the use of ultrasonography to establish criteria for somatic dysfunction.

The Thoracic Lordosis Correction Improves Sacral Slope and Walking Ability in Neuromuscular Scoliosis.

PubMed

Kim, Do Yeon; Moon, Eun Su; Park, Jin Oh; Chong, Hyon Su; Lee, Hwan Mo; Moon, Seong Hwan; Kim, Sung Hoon; Kim, Hak Sun

2016-10-01

Retrospective study. To report on neuromuscular patients with preserved walking ability, but forward bending of the body due to thoracic lordosis, and to suggest thoracic lordosis correction as the surgical treatment. It is an established fact that lumbar lordosis or pelvic parameter is directly related to thoracic sagittal balance. However, the reverse relationship has not been fully defined yet. Loss of thoracic kyphosis results in positive sagittal balance, which causes walking difficulty. Neuromuscular patients with thoracic lordosis have not been reported yet, and there have been no reports on their surgical treatments. This study analyzed 8 patients treated with thoracic lordosis correction surgery. Every patient was diagnosed with muscular dystrophy. In thoracic lordosis correction surgery, anterior release was performed in the first stage and posterior segmental instrumentation was performed in the second stage. Radiographic parameters were compared and walking ability was evaluated with gait analysis. All patients were classified according to the modified Rancho Los Amigos Hospital system preoperatively and 2 years postoperatively to evaluate functional ability. The average follow-up period was 2.9 years. Before surgery, the mean thoracic sagittal alignment was -2.1-degree lordosis, the mean Cobb angle and sacral slope increased to 36.3 and 56.6 degrees, respectively. The anterior pelvic tilt in gait analysis was 29.3 degrees. At last follow-up after surgery, the mean thoracic sagittal alignment changed to 12.6-degree kyphosis, and the Cobb angle and sacral slope decreased to 18.9 and 39.5 degrees, respectively. Lumbar lordosis and the sacral slope showed significant positive correlation (P<0.001). The improvement in thoracic lordosis showed a significant correlation to the preoperative flexibility of the major curve (P=0.028). The anterior pelvic tilt in gait analysis improved to 15.4 degrees. The functional ability improved in 2 (50%) of 4 patients in class 2 and maintained in remaining 6 patients 2 years after surgery. Thoracic lordosis correction surgery in neuromuscular scoliosis patients with thoracic lordosis improved the sacral slope in the standing position and the anterior pelvic tilt in gait. Sagittal imbalance was compensated by the spinopelvic mechanism, and back and hip extensor muscles seem to play a major role in this compensation.

Preclinical assessment of potential interactions between botulinum toxin and neuromodulation for bladder micturition reflex.

PubMed

Su, Xin; Nickles, Angela; Nelson, Dwight E

2015-06-09

While botulinum toxin A (BoNT-A) has become a more commonly used second-line treatment for patients with detrusor overactivity, it remains unknown whether the impacts of this therapy may persist to influence other therapies such as sacral neuromodulation. In this preclinical study we have evaluated urodynamic functions to intradetrusor injection of BoNT-A and the bladder inhibitory effects of spinal nerve stimulation (SNS) following BoNT-A treatment. Female rats were anesthetized with 3 % isoflurane. BoNT-A (2 units, 0.2 ml) or saline were injected into the detrusor. Rats then were housed for 2 days to 1 month before neuromodulation study. Monopolar electrodes were placed under each of the L6 spinal nerve bilaterally under urethane anesthesia. A bladder cannula was inserted via the urethra for saline infusion and intravesical pressure recording. Intradetrusor injection of BoNT-A for 1-2 weeks or 1 month significantly increased bladder capacity compared with saline injection (p < 0.05, two-way ANOVA). Following BoNT-A, SNS attenuated the frequency of bladder contractions, either eliminating bladder contractions or reducing the contraction frequency during electrical stimulation. Inhibition of the contraction frequency by SNS following BoNT-A treated rats was not different from that measured following saline injection. BoNT-A increased the bladder capacity, but compensating for additional saline infusion to the enlarged urinary bladder in BoNT-A pretreated rats, the bladder contractions induced by bladder filling were attenuated by SNS. BoNT-A did not alter the ability of SNS to inhibit bladder contraction following intradetrusor injection of BoNT-A for 2 days, 1-2 weeks or 1 month. These results support further pre-clinical and clinical studies to evaluate potential interactions or combination therapy with neuromodulation and intradetrusor BoNT-A therapeutic approaches.

The efficacy and safety of high-intensity focused ultrasound ablation of benign thyroid nodules.

PubMed

Lang, Brian H; Wu, Arnold L H

2018-04-01

High-intensity focused ultrasound (HIFU) is a promising form of thermal ablation of benign thyroid nodules, but evidence supporting its use is scarce. The present review evaluated the efficacy and safety of single-session HIFU treatment of benign thyroid nodules. As reported in the literature, the extent of nodule shrinkage following treatment ranged from 48.8% to 68.8%. Like other forms of ablation, the shrinkage rate was greatest in the first 3-6 months, and the best responders were patients with small (≤10 mL) nodules. Complications were uncommon, but temporary vocal cord palsy occurred in 3%-4% of patients, and was related to the distance between the HIFU beam and the recurrent laryngeal nerve. Despite being safe and efficacious, a larger-scale prospective trial is required.

The role of regional nerve block anesthesia for carotid endarterectomy: an experimental comparison with previous series with the use of general anesthesia and barbiturates for cerebral protection.

PubMed

Agrifoglio, G; Agus, G B; Bonalumi, F; Costantini, A; Carlesi, R

1987-01-01

A retrospective analysis was performed on a consecutive series of 60 cases divided into two groups given carotid endarterectomy (C.E.) for atherosclerotic disease. In the first group general anesthesia and barbiturate cerebral protection were employed; in group two, loco-regional anesthesia. Indications and risk factors were similar in the two groups; the surgical procedure was identical. The differences in the results are reported and factors contributing to cerebral protection or reduction in the risk of stroke are analyzed. The analysis indicates that loco-regional anesthesia for C.E. is a reliable method for detecting cerebral ischemia and guaranteeing cerebral protection by means of a temporary shunt when strictly necessary.

Prevention and treatment of recurrent laryngeal nerve injury in thyroid surgery

PubMed Central

Jiang, Yan; Gao, Bo; Zhang, Xiaohua; Zhao, Jianjie; Chen, Jinping; Zhang, Shu; Luo, Donglin

2014-01-01

Aim: To summary the experience for prevention and treatment of recurrent laryngeal nerve (RLN) injury in thyroid surgery. Methods: Clinical features of 623 patients who received thyroid surgery from January 2010 to December 2012 were analyzed retrospectively, and the features of RLN injury and intraoperative as well as postoperative treatments were reviewed. Results: RLN injury occurred in 31 patients (4.98%), in which, unilateral RLN injury occurred in 27 patients and bilateral RLN injuries occurred in 4 patients (temporary injury in 28 patients and permanent injury in 3 patients). 6 patients underwent RLN anastomosis during surgery and exhibited transient hoarseness after surgery. RLN exploration and decompression was given in 1 patient and the patient got normal vocal cord motion 2 months after surgery. 1 patient with bilateral injuries received tracheotomy and CO2 laser resection of arytenoid cartilage and achieved recovery 1 year later. Conclusions: In order to prevent RLN injury, the anatomic variations of RLN should be mastered. Routine exposure of RLN can effectively prevent the injury in patients receiving the second or multiple surgeries. Early interventions for RLN injury include mainly early discovery, early exploration and early anastomosis, and the function of RLN in some patients can recover completely. Subsequent treatments mainly focus on the improvement of the voice, expansion of glottis and melioration of dyspnea. PMID:24482694

Pan-brachial plexus neuropraxia following lightning: A rare case report.

PubMed

Patnaik, Ashis; Mahapatra, Ashok Kumar; Jha, Menka

2015-01-01

Neurological complications following lightning are rare and occur in form of temporary neurological deficits of central origin. Involvement of peripheral nervous system is extremely rare and only a few cases have been described in the literature. Isolated unilateral pan-brachial plexus neuropraxia has never been reported in the literature. Steroids have long been used for treatment of neuropraxia. However, their use in lightning neural injury is unique and requires special mention. We report a rare case of lightning-induced unilateral complete flaccid paralysis along with sensory loss in a young patient. Lightning typically causes central nervous involvement in various types of motor and sensory deficit. Surprisingly, the nerve conduction study showed the involvement of peripheral nervous system involvement. Steroids were administered and there was significant improvement in neurological functions within a short span of days. Patients' functions in the affected limb were normal in one month. Our case was interesting since it is the first such case in the literature where lightning has caused such a rare instance of unilateral pan-brachial plexus lesion. Such cases when seen, raises the possibility of more common central nervous system pathology rather than peripheral involvement. However, such lesions can be purely benign forms of peripheral nerve neuropraxia, which can be managed by steroid treatment without leaving any long-term neurological deficits.

Functional Reintegration of Sensory Neurons and Transitional Dendritic Reduction of Mitral/Tufted Cells during Injury-Induced Recovery of the Larval Xenopus Olfactory Circuit.

PubMed

Hawkins, Sara J; Weiss, Lukas; Offner, Thomas; Dittrich, Katarina; Hassenklöver, Thomas; Manzini, Ivan

2017-01-01

Understanding the mechanisms involved in maintaining lifelong neurogenesis has a clear biological and clinical interest. In the present study, we performed olfactory nerve transection on larval Xenopus to induce severe damage to the olfactory circuitry. We surveyed the timing of the degeneration, subsequent rewiring and functional regeneration of the olfactory system following injury. A range of structural labeling techniques and functional calcium imaging were performed on both tissue slices and whole brain preparations. Cell death of olfactory receptor neurons and proliferation of stem cells in the olfactory epithelium were immediately increased following lesion. New olfactory receptor neurons repopulated the olfactory epithelium and once again showed functional responses to natural odorants within 1 week after transection. Reinnervation of the olfactory bulb (OB) by newly formed olfactory receptor neuron axons also began at this time. Additionally, we observed a temporary increase in cell death in the OB and a subsequent loss in OB volume. Mitral/tufted cells, the second order neurons of the olfactory system, largely survived, but transiently lost dendritic tuft complexity. The first odorant-induced responses in the OB were observed 3 weeks after nerve transection and the olfactory network showed signs of major recovery, both structurally and functionally, after 7 weeks.

Functional Reintegration of Sensory Neurons and Transitional Dendritic Reduction of Mitral/Tufted Cells during Injury-Induced Recovery of the Larval Xenopus Olfactory Circuit

PubMed Central

Hawkins, Sara J.; Weiss, Lukas; Offner, Thomas; Dittrich, Katarina; Hassenklöver, Thomas; Manzini, Ivan

2017-01-01

Understanding the mechanisms involved in maintaining lifelong neurogenesis has a clear biological and clinical interest. In the present study, we performed olfactory nerve transection on larval Xenopus to induce severe damage to the olfactory circuitry. We surveyed the timing of the degeneration, subsequent rewiring and functional regeneration of the olfactory system following injury. A range of structural labeling techniques and functional calcium imaging were performed on both tissue slices and whole brain preparations. Cell death of olfactory receptor neurons and proliferation of stem cells in the olfactory epithelium were immediately increased following lesion. New olfactory receptor neurons repopulated the olfactory epithelium and once again showed functional responses to natural odorants within 1 week after transection. Reinnervation of the olfactory bulb (OB) by newly formed olfactory receptor neuron axons also began at this time. Additionally, we observed a temporary increase in cell death in the OB and a subsequent loss in OB volume. Mitral/tufted cells, the second order neurons of the olfactory system, largely survived, but transiently lost dendritic tuft complexity. The first odorant-induced responses in the OB were observed 3 weeks after nerve transection and the olfactory network showed signs of major recovery, both structurally and functionally, after 7 weeks. PMID:29234276

Effect of Acupuncture on Post-implant Paresthesia.

PubMed

Sant'Anna, Crischina Branco Marques; Zuim, Paulo Renato Junqueira; Brandini, Daniela Atili; Guiotti, Aimée Maria; Vieira, Joao Batista; Turcio, Karina Helga Leal

2017-04-01

Paresthesia is defined as an alteration in local sensibility, associated with numbness, tingling, or unpleasant sensations caused by nerve lesions or irritation. It can be temporary or permanent. The treatment protocol for facial paresthesia is primarily based on the use of drugs and implant removal, which may not be completely effective or may require other risk exposure when there is no spontaneous regression. However, other therapeutic modalities such as acupuncture can be used. The aim of this study is to report a case of a patient with paresthesia of the inferior alveolar nerve and pain caused by an implant surgery performed 2 years earlier. The patient received acupuncture treatment during 4 months of weekly sessions. Six points were used: Large Intestine (LI4), Large Intestine (LI11), Stomach (ST36), Liver (LR3), Extra Head and Neck (E-HN-18), and Stomach (ST5). The visual analog scale was used before and after each session for the analysis of paresthesia and pain, together with assessment of the paresthesia by delimitation of the desensitized region of the skin and presented discomfort. Pain remission and reduction in the size of the paresthesia area occurred after four sessions. Copyright © 2017 Medical Association of Pharmacopuncture Institute. Published by Elsevier B.V. All rights reserved.

Piezosurgery for the lingual split technique in mandibular third molar removal: a suggestion.

PubMed

Pippi, Roberto; Alvaro, Roberto

2013-03-01

The lingual split technique is a surgical procedure for extraction of impacted mandibular third molar throughout a lingual approach. The main disadvantage of this technique is the high rate of temporary lingual nerve injury mainly because of the trauma induced by the lingual flap retraction. The purpose of this paper is to suggest the use of piezosurgery in performing the lingual cortical plate osteotomy of the third molar alveolar process. Surgical procedure was performed under general anesthesia, and it lasted approximately 60 minutes. After the buccal and lingual full-thickness flaps were incised and elevated, a piezosurgical device was used for osteotomy. A well-defined bony window was then removed, and it allowed the entire tooth was extracted in a lingual direction. The patient did not show any neurological postoperative complication. Lingual and inferior alveolar nerve functionality was normal before as well as after surgery. The use of piezoelectric surgery seems to be a good option in removing lower third molars when a lingual access is clearly indicated. The only disadvantage of this technique can be represented by an operating time lengthening possibly because of a lower power cut of the piezoelectric device, to the high mineralization of the mandibular cortical bone and to the use of inserts with a low degree of sharpening.

[Orthodontic Management of the Impacted Mandibular Second Molar Tooth].

PubMed

Mah, Michael; Takada, Kenji

2016-09-01

When the mandibular permanent second molar becomes impacted, it is identified as a malocclusion that needs treatment as it often leads to unwanted complications such as caries and periodontitis of the adjacent permanent first molar. Other less common complications include root resorption of the adjacent first molar root or continued root development to be in close proximity to the inferior dental alveolar nerve. This paper seeks to differentiate various levels of severity of impaction and review treatment options that are considered clinically available for the proper management of the impacted mandibular permanent second molar. Treatment options that will be discussed in this article include timing of second molar removal for replacement by the third molar, relief of impaction via second premolar removal, surgical repositioning and the combination of third molar removal, surgical exposure and orthodontic uprighting of the impacted tooth. Depending on the severity of the impaction, most impactions can be easily and predictably corrected with nickel titanium archwires or auxillary open coil springs or uprighting springs. Uncommonly, the mandibular permanent second molar can become severely impacted and in close proximity to the inferior dentoalveolar nerve. In these instances, the use of temporary anchorage devices such as microimplants has shown to be successful in uprighting the severely impacted mandibular permanent second molars. © EDP Sciences, SFODF, 2016.

Morphometric study of the true S1 and S2 of the normal and dysmorphic sacralized sacra.

PubMed

Firat, Ayşegül; Alemdaroğlu, Kadir Bahadır; Özmeriç, Ahmet; Yücens, Mehmet; Göksülük, Dinçer

2017-06-12

This study aimed to generate data for the S1 and S2 alar pedicle and body and the alar orientations for both dysmorphic and normal sacra. The study comprised two groups: Group N consisted of 53 normal sacra and Group D included 10 dysmorphic sacra. Various features such as alar pedicle circumference; anterior, middle, and posterior axis of the sacral ala; sacral body height and width; and sagittal thickness were measured. In group N, the median anterior axis of the alae was observed to be 30° on the right and 25° on the left, the median midline axis was found to be 20° on the right and 15° on the left, and the median posterior alar axis was -15° on the right and -20° on the left. The true S1 and S2 alar pedicle circumferences were observed to be significantly smaller in group D, which demonstrated a shorter S1 alar pedicle mean circumference, significantly narrower S1 body mean width, and considerably tapered sagittal thickness. Our analysis indicated that dysmorphic sacra have a lower sagittal thickness and width of bodies and smaller alar pedicles, which explains the difficulties in their percutaneous fixation.

Effects of acute urinary bladder overdistension on bladder response during sacral neurostimulation.

PubMed

Bross, S; Schumacher, S; Scheepe, J R; Zendler, S; Braun, P M; Alken, P; Jünemann, K

1999-10-01

Urinary retention and micturition disorders after overdistension are clinically well-known complications of subvesical obstruction. We attempted to evaluate whether bladder overdistension influences bladder response and whether overdistension supports detrusor decompensation. Following lumbal laminectomy in 9 male foxhounds, the sacral anterior roots S2 and S3 were placed into a modified Brindley electrode for reproducible and controlled detrusor activation. The bladder was filled in stages of 50 ml from 0 to 700 ml, corresponding to an overdistension. At each volume, the bladder response during sacral anterior root stimulation was registered. After overdistension, the bladder was refilled stepwise from 0 to 300 ml and stimulated. In all dogs, the bladder response was influenced by the intravesical volume. The maximum pressure (mean 69.1 cm H(2)O) was observed at mean volume of 100 ml. During overdistension, a significant reduction in bladder response of more than 80% was seen. After overdistension, a significant reduction in intravesical pressure of 19.0% was observed. In 2 cases, reduction in bladder response was more than 50% after a single overdistension. We conclude that motoric bladder function is influenced during and after overdistension. A single bladder overdistension can support acute and long-lasting detrusor decompensation. In order to protect motoric bladder function, bladder overdistension must be prevented.

Lumbosacral pain in ballet school students. Pilot study.

PubMed

Drężewska, Marlena; Śliwiński, Zbigniew

2013-01-01

The unique biomechanical demands placed on ballet students predispose to injury and pain. The aim of this study was to evaluate the prevalence of lumbosacral pain in ballet school students and to identify possible risk factors for the pain. The study group comprised 71 ballet school students, including 45 females and 26 males, aged 15-18 years (mean 16.5 years). In order to identify possible risk factors for pain, a survey was conducted, the angle of sacral bone inclination was measured using a mechanical inclinometer and the BMI was calculated. A VAS scale was used for a subjective assessment of pain intensity. Low back pain was reported by 44 patients (62%). A comparison of sacral inclination angles in a position with the feet placed parallel and in the turnout position showed statistically significant changes in the angle among respondents reporting pain (p <0.05). 1. Compensation in the turnout position by increas ed anterior tilt of the pelvis may increase the risk of low back pain. 2. An angle of sacral bone inclination in turnout above or equal to 30° can increase the intensity of low back pain. 3. A BMI below 18.5 in female ballet school stu dents can increase the risk of lumbosacral pain.

Failure of Urological Implants in Spinal Cord Injury Patients due to Infection, Malfunction, and Implants Becoming Obsolete due to Medical Progress and Age-Related Changes in Human Body Making Implant Futile: Report of Three Cases.

PubMed

Vaidyanathan, Subramanian; Soni, Bakul; Singh, Gurpreet; Hughes, Peter; Selmi, Fahed; Mansour, Paul

2013-01-01

Any new clinical data, whether positive or negative, generated about a medical device should be published because health professionals should know which devices do not work, as well as those which do. We report three spinal cord injury patients in whom urological implants failed to work. In the first, paraplegic, patient, a sacral anterior root stimulator failed to produce erection, and a drug delivery system for intracavernosal administration of vasoactive drugs was therefore implanted; however, this implant never functioned (and, furthermore, such penile drug delivery systems to produce erection had effectively become obsolete following the advent of phosphodiesterase type 5 inhibitors). Subsequently, the sacral anterior root stimulator developed a malfunction and the patient therefore learned to perform self-catheterisation. In the second patient, also paraplegic, an artificial urinary sphincter was implanted but the patient developed a postoperative sacral pressure sore. Eight months later, a suprapubic cystostomy was performed as urethral catheterisation was very difficult. The pressure sore had not healed completely even after five years. In the third case, a sacral anterior root stimulator was implanted in a tetraplegic patient in whom, after five years, a penile sheath could not be fitted because of penile retraction. This patient was therefore established on urethral catheter drainage. Later, infection with Staphylococcus aureus around the receiver block necessitated its removal. In conclusion, spinal cord injury patients are at risk of developing pressure sores, wound infections, malfunction of implants, and the inability to use implants because of age-related changes, as well as running the risk of their implants becoming obsolete due to advances in medicine. Some surgical procedures such as dorsal rhizotomy are irreversible. Alternative treatments such as intermittent catheterisations may be less damaging than bladder stimulator in the long term.

Contribution of GABAA, Glycine, and Opioid Receptors to Sacral Neuromodulation of Bladder Overactivity in Cats.

PubMed

Jiang, Xuewen; Fuller, Thomas W; Bandari, Jathin; Bansal, Utsav; Zhang, Zhaocun; Shen, Bing; Wang, Jicheng; Roppolo, James R; de Groat, William C; Tai, Changfeng

2016-12-01

In α-chloralose-anesthetized cats, we examined the role of GABA A , glycine, and opioid receptors in sacral neuromodulation-induced inhibition of bladder overactivity elicited by intravesical infusion of 0.5% acetic acid (AA). AA irritation significantly (P < 0.01) reduced bladder capacity to 59.5 ± 4.8% of saline control. S1 or S2 dorsal root stimulation at threshold intensity for inducing reflex twitching of the anal sphincter or toe significantly (P < 0.01) increased bladder capacity to 105.3 ± 9.0% and 134.8 ± 8.9% of saline control, respectively. Picrotoxin, a GABA A receptor antagonist administered i.v., blocked S1 inhibition at 0.3 mg/kg and blocked S2 inhibition at 1.0 mg/kg. Picrotoxin (0.4 mg, i.t.) did not alter the inhibition induced during S1 or S2 stimulation, but unmasked a significant (P < 0.05) poststimulation inhibition that persisted after termination of stimulation. Naloxone, an opioid receptor antagonist (0.3 mg, i.t.), significantly (P < 0.05) reduced prestimulation bladder capacity and removed the poststimulation inhibition. Strychnine, a glycine receptor antagonist (0.03-0.3 mg/kg, i.v.), significantly (P < 0.05) increased prestimulation bladder capacity but did not reduce sacral S1 or S2 inhibition. After strychnine (0.3 mg/kg, i.v.), picrotoxin (0.3 mg/kg, i.v.) further (P < 0.05) increased prestimulation bladder capacity and completely blocked both S1 and S2 inhibition. These results indicate that supraspinal GABA A receptors play an important role in sacral neuromodulation of bladder overactivity, whereas glycine receptors only play a minor role to facilitate the GABA A inhibitory mechanism. The poststimulation inhibition unmasked by blocking spinal GABA A receptors was mediated by an opioid mechanism. Copyright © 2016 by The American Society for Pharmacology and Experimental Therapeutics.

The effect of early operative stabilization on late displacement of zone I and II sacral fractures.

PubMed

Emohare, Osa; Slinkard, Nathaniel; Lafferty, Paul; Vang, Sandy; Morgan, Robert

2013-02-01

This study was designed to evaluate the effect on displacement of early operative stabilization on unstable fractures when compared to stable fractures of the sacrum. Patient consisted of those sustaining traumatic pelvic fractures that also included sacral fractures of Denis type I and type II classification, who were over 18 at the time of the study. Patients were managed emergently, as judged appropriate at the time and then subsequently divided into two cohorts, comprising those who were either treated operatively or non-operatively. The operative group comprised those treated with either internal fixation or external fixation. Twenty-eight patients had zone II fractures, and 20 had zone I fractures. Zone II fractures showed average displacements of 6.5mm and 6.9mm in the rostral-caudal and anteroposterior directions, respectively, at final follow up. Zone I fractures had average displacements of 6.6mm and 6.1mm in both directions. There were no significant differences between zone I and II sacral fractures (rostral-caudal P=0.74, anteroposterior P=0.24). Average changes in fracture displacement in patients with zone I fractures were 0.6-1.0mm in both directions. Average changes in zone II fractures were 1.8-1.5mm in both directions. There were no significant differences between the average changes in zone I and II fractures in any direction (rostral-caudal P=0.64, anteroposterior P=0.68) or in average displacements at final follow up in any of zone or the entire cohort. Statistically significant differences were noted in average changes in displacement in zone II fractures in the anteroposterior plane (P=0.03) and the overall cohort in the anteroposterior plane (P=0.02). Operative fixation for unstable sacral fractures ensures displacement at follow up is comparable with stable fractures treated non operatively. Copyright © 2012 Elsevier Ltd. All rights reserved.

Role of Anatomical Landmarks in Identifying Normal and Transitional Vertebra in Lumbar Spine Magnetic Resonance Imaging

PubMed Central

Indiran, Venkatraman; Hithaya, Fouzal; Alamelu, M.; Padmanaban, S.

2017-01-01

Study Design Retrospective study. Purpose Identification of transitional vertebra is important in spine imaging, especially in presurgical planning. Pasted images of the whole spine obtained using high-field magnetic resonance imaging (MRI) are helpful in counting vertebrae and identifying transitional vertebrae. Counting vertebrae and identifying transitional vertebrae is challenging in isolated studies of lumbar spine and in studies conducted in low-field MRI. An incorrect evaluation may lead to wrong-level treatment. Here, we identify the location of different anatomical structures that can help in counting and identifying vertebrae. Overview of Literature Many studies have assessed the vertebral segments using various anatomical structures such as costal facets (CF), aortic bifurcation (AB), inferior vena cava confluence (IC), right renal artery (RRA), celiac trunk (CT), superior mesenteric artery root (SR), iliolumbar ligament (ILL) psoas muscle (PM) origin, and conus medullaris. However, none have yielded any consistent results. Methods We studied the locations of the anatomical structures CF, AB, IC, RRA, CT, SR, ILL, and PM in patients who underwent whole spine MRI at our department. Results In our study, 81.4% patients had normal spinal segmentation, 14.7% had sacralization, and 3.8% had lumbarization. Vascular landmarks had variable origin. There were caudal and cranial shifts with respect to lumbarization and sacralization. In 93.8% of cases in the normal group, ILL emerged from either L5 alone or the adjacent disc. In the sacralization group, ILL was commonly seen in L5. In the lumbarization group, ILL emerged from L5 and the adjacent disc (66.6%). CFs were identified at D12 in 96.9% and 91.7% of patients in the normal and lumbarization groups, respectively. The PM origin was observed from D12 or D12–L1 in most patients in the normal and sacralization groups. Conclusions CF, PM, and ILL were good identification markers for D12 and L5, but none were 100% accurate. PMID:28670404

Application of posterior pelvic tilt taping for the treatment of chronic low back pain with sacroiliac joint dysfunction and increased sacral horizontal angle.

PubMed

Lee, Jung-hoon; Yoo, Won-gyu

2012-11-01

Kinesio Taping (KT) is a therapeutic method used by physical therapists and athletic trainers in combination with other treatment techniques for various musculoskeletal and neuromuscular problems. However, no research has evaluated the effect of KT in patients with low back pain (LBP). The purpose of this case was to describe the application of posterior pelvic tilt taping (PPTT) with Kinesio tape as a treatment for chronic LBP and to reduce the anterior pelvic tilt angle. Case report. The patien was a 20-year-old female amateur swimmer with a Cobb's angle (L1-S1) of 68°, a sacral horizontal angle of 45°, and pain in both medial buttock areas and sacroiliac joints. We performed PPTT with Kinesio tape for 2 weeks (six times per week for an average of 9 h each time). The patient’s radiographs showed that the Cobb's angle (L1-S1) had decreased from 68° to 47° and that the sacral horizontal angle had decreased from 45° to 31°. Reductions in hypomobility or motion asymmetry, as assessed by the motion palpation test, and in pain, as measured by the pain-provocation tests, were observed. On palpation for both medial buttock areas in the prone position, the patient felt no pain. The patient experienced no pain or stiffness in the low back area while performing forward flexion in the standing position with knees fully extended when washing dishes in the sink. The case study demonstrated that PPTT intervention favourably affected the pelvic inclination and sacral horizontal angle, leading to beneficial effects on sacroiliac joint dysfunction (SIJD) and medial buttock pain. Additional research on the clinical effects of this taping procedure requires greater numbers of athletes with SIJD or LBP who have inappropriate anterior pelvic tilt angles and hyperlordosis.

Onset of Action of Sacral Neuromodulation in Lower Urinary Tract Dysfunction-What is the Optimal Duration of Test Stimulation?

PubMed

Jairam, Ranjana; Drossaerts, Jamie; Marcelissen, Tom; van Koeveringe, Gommert; van Kerrebroeck, Philip

2018-06-01

Since the development of sacral neuromodulation, a large number of patients with lower urinary tract symptoms have been treated with this procedure. A test stimulation is performed prior to implantation. At centers worldwide the duration of this test stimulation varies considerably since it is not certain when the onset of the therapy effect can be expected. The objective of this prospective study was to evaluate the average onset time of sacral neuromodulation in patients with lower urinary tract symptoms. All patients who were eligible for treatment with sacral neuromodulation were asked to participate in this study. A voiding diary was filled out prior to and during test stimulation using an implanted tined lead. Success was defined as a 50% or greater improvement compared to baseline in any of the main complaint parameters. The Mann-Whitney U test was used to compare the mean time to success between patients with overactive bladder syndrome and patients with nonobstructive urinary retention. Of the 45 patients 24 with nonobstructive urinary retention and 21 with overactive bladder syndrome agreed to participate and were included in study. Test stimulation was successful in 29 patients (64%). Mean time to success in all patients was 3.3 days (range 1 to 9). There was no significant difference in mean time to success between cases of overactive bladder syndrome and nonobstructive urinary retention (3.25 and 3.5 days, respectively, p = 0.76). The results imply that a test stimulation of more than 2 weeks is not necessary if a cutoff of 50% or greater improvement is adopted. However, further improvement can be expected with prolonged test stimulation. This might be important since it might have implications for long-term results. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Electrical stimulation for lower urinary tract dysfunction in children: a systematic review of the literature.

PubMed

Barroso, Ubirajara; Tourinho, Rafael; Lordêlo, Patrícia; Hoebeke, Piet; Chase, Janet

2011-11-01

To review studies using electrical neural stimulation (ENS), to treat children with non-neurogenic lower urinary tract dysfunctions (LUTD), and to establish the efficacy of this treatment. This review was based on an electronic search of the MEDLINE database and the Cochrane Central Search library, from January 1990 to March 2010. (1) participants aged 0-17 years, (2) participants with a diagnosis of LUTD not related to congenital abnormalities or neurological disease, (3) English language, and (4) treatment by ENS. Seventeen papers were evaluated. Type of ENS varied among studies: sacral transcutaneous ENS in seven, sacral implanted device in four, posterior tibial percutaneous in three, and anogenital, endoanal, and intravesical in one each. There were two randomized clinical trials. Clarity regarding the LUTD being treated was variable. The populations studied were not homogeneous. The duration of treatment and the number of sessions a week were variable among the studies. Electrical parameters used also varied. A range of subjective and objective measures was used to measure treatment success. Rates of complete resolution of the symptoms of OAB, urgency, and daytime incontinence ranged from 31% to 86% [Trsinar and Kraij, Neurourol Urodyn 15: 133-42, 1996; Hagstroem et al., J Urol 182: 2072-8, 2009], 25% to 84% [Hoebeke et al., J Urol 168: 2605-8, 2002; Lordêlo et al., J Urol 182: 2900-4, 2009], 13% to 84% [Malm-Buatsi et al., Urology 70: 980-3, 2007; Lordêlo et al., J Urol 184: 683-9, 2010], respectively. For sacral transcutaneous ENS recurrence ranged from 10% to 25%. Apart from the sacral implantation studies, any reported side effects were mild and transitory. The literature in the area of interest is sparse. Parasacral TENS has been shown to be more effective than sham in randomized trials in treating OAB. This deserves further research to elucidate the optimal parameters and the children for whom it is most useful. Copyright © 2011 Wiley Periodicals, Inc.

[Diagnosis and treatment of congenital fourth branchial anomaly].

PubMed

Chen, Liang-si; Zhang, Si-yi; Luo, Xiao-ning; Song, Xin-han; Zhan, Jian-dong; Chen, Shao-hua; Lu, Zhong-ming

2010-10-01

To discuss the anatomic features, clinical presentations, diagnosis, differentiations and treatments of congenital fourth branchial anomaly(CFBA). The clinical data of 8 patients with CFBA were retrospectively analyzed. Of the 8 patients aging from 27 to 300 months (median age: 114 months), 4 male and 4 female; 3 untreated previously and 5 recurrent. All lesions, including 1 cyst, 3 sinus (with internal opening) and 4 fistula, located in the left necks. Three patients presented acute suppurative thyroiditis, 4 deep neck abscesses, and 1 neck lump. Preoperative examinations included barium esophagogram, direct laryngoscopy, ultrasonography, CT, MRI, and so on. The principles of managements were adequate drainage, infection control during acute period and radical surgery during quiescent period. Classic surgical approach consisted of complete excision of branchial lesions, dissection of recurrent laryngeal nerve and partial thyroidectomy. Selective neck dissection was applied in recurrent cases to extirpate branchial lesions, scarrings and inflammatory granuloma. Postoperatively, 1 case was with local incision infection which healed by wound care; 1 case was with temporary vocal cord paralysis which completely recovered 1 month after operation. No recurrence was found in all of 8 cases with follow-up of 13 to 42 months (median: 21 months). CFBA relates closely anatomically with recurrent laryngeal nerve and thyroid grand. The barium esophagogram and direct laryngoscopy are the most useful diagnostic tools. CT and MRI are all beneficial to the diagnosis of CFBA. The treatment key to CFBA is the complete excision of lesion during a quiescent period after inflammatory control, together with the dissection of recurrent laryngeal nerve, partial thyroidectomy and partial resection of lamina of thyroid cartilage (if necessary), which all can decrease the risk of complications and recurrence. For recurrent cases, selective neck dissection is a safe and effective surgical procedure.

Trigemino-gustatory interactions: a randomized controlled clinical trial assessing the effects of selective anesthesia of dental afferents on taste thresholds.

PubMed

Lecor, Papa Abdou; Touré, Babacar; Boucher, Yves

2018-03-01

This study aimed at analyzing the effect of the temporary removal of trigeminal dental afferents on electrogustometric thresholds (EGMt). EGMt were measured in 300 healthy subjects randomized in three groups, in nine loci on the right and left side (RS, LS) of the tongue surface before and after anesthesia. Group IAN (n = 56 RS, n = 44 LS) received intraosseous local anesthesia of the inferior alveolar nerve (IAN). Group MdN received mandibular nerve (MdN) block targeting IAN before its entrance into the mandibular foramen (n = 60, RS, and n = 40, LS); group MxN receiving maxillary nerve (MxN) anesthesia (n = 56 RS and n = 44 LS) was the control group. Differences between mean EGMt were analyzed with the Wilcoxon test; correlation between type of anesthesia and EGMt was performed with Spearman's rho, all with a level of significance set at p ≤ 0.05. Significant EGMt (μA) differences before and after anesthesia were found in all loci with MdN and IAN on the ipsilateral side (p < 0.05), but not with MxN. Anesthesia of the MdN was positively correlated with the increase in EGMt (p < 0.001). Selective anesthesia of IAN was positively correlated only with the increase in EGMt measured at posterior and dorsal loci of the tongue surface (p < 0.01). The increase in EGMt following IAN anesthesia suggests a participation of dental afferents in taste perception. Extraction of teeth may impair food intake not only due to impaired masticatory ability but also to alteration of neurological trigemino-gustatory interactions. PACTR201602001452260.

[Three-dimensional computed tomography analysis and clinical application of sacroiliac screw placement].

PubMed

Yin, Y C; Zhang, R P; Li, S L; Hou, Z Y; Chen, W; Zhang, Y Z

2018-03-01

Objective: To evaluate the possibility of transverse sacroiliac screw placement in different segments of the sacrum. Methods: Data of 80 pelvic CT scans (slice thickness ≤1.0 mm) archived in CT department of the Third Hospital of Hebei Medical University from September 2016 to October 2017 were retrospectively collected. Mimics software was used to rebuild the pelvis three-dimensional model. According to whether the sacral 1(S(1)) segment could place the transverse sacroiliac screws or not, all the sacrums were divided into normal group ( n =55) and dysmorphic group ( n =25). Simulation the S(1), sacral 2(S(2)) transverse sacroiliac screw placement in 3-Matic software. Analysis whether there was any difference in maximum diameter and length of S(2) transverse sacroiliac screw between the normal group and the dysmorphic group. The pelvic CT data of the dysmorphic group were measured, and the optimal tilt angle and length of the oblique S(1) screw were obtained. The feasibility of transverse sacroiliac screw insertion in sacral 3(S(3)) segment was evaluated. t -test, rank sum test, and χ(2) test was used to analyze data, respectively. Results: In the dysmorphic group, the largest diameter of the S(1) transverse screw was (4.9±1.6)mm, and the normal group was (13.6±3.6)mm ( t =-15.07, P =0.00). In the dysmorphic group, the largest diameter of S(2) transverse screw was (13.8±3.0)mm, and was (12.4±2.2)mm in the normal group( t =2.11, P =0.04). There was no significant difference in the length of S(2) transverse sacroiliac screw between the two groups ( t =0.47, P =0.64). In the dysmorphic group, the anterior vertebral height of S(1) was (23.1±4.0)mm, which was significantly higher than that of the normal group ((14.1±4.2)mm)( t =9.01, P =0.00). The angle of S(1)S(2) in the dysmorphic group was 10.9°(3.8°, 17.6°), which was significantly larger than that of the normal group (2.0°(1.0°, 2.0°) ( Z =-4.03, P =0.00). In the dysmorphic group, the incline angle of the oblique S(1) sacroiliac screw was (35.6±6.2)°, the anteversion angle was (37.2±4.4)°, and the mean screw length was (90.2±4.7)mm. In the dysmorphic group, the placement rate of S(3) transverse sacroiliac screw was 48.0%, and that of the normal sacral group was 9.1%. Conclusions: There is often dysmorphic in the sacrum in patients with large S(1) anterior vertebral height and S(1)S(2) angle. Sacral dysmorphic patients with posterior pelvic ring injury may be treated with S(1) pedicle oblique sacroiliac screws. S(3) transverse sacroiliac screws should be carefully placed, especially for the absence of sacral dysmorphic in patients.

Temporary hearing loss influences post-stimulus time histogram and single neuron action potential estimates from human compound action potentials

PubMed Central

Lichtenhan, Jeffery T.; Chertoff, Mark E.

2008-01-01

An analytic compound action potential (CAP) obtained by convolving functional representations of the post-stimulus time histogram summed across auditory nerve neurons [P(t)] and a single neuron action potential [U(t)] was fit to human CAPs. The analytic CAP fit to pre- and postnoise-induced temporary hearing threshold shift (TTS) estimated in vivoP(t) and U(t) and the number of neurons contributing to the CAPs (N). The width of P(t) decreased with increasing signal level and was wider at the lowest signal level following noise exposure. P(t) latency decreased with increasing signal level and was shorter at all signal levels following noise exposure. The damping and oscillatory frequency of U(t) increased with signal level. For subjects with large amounts of TTS, U(t) had greater damping than before noise exposure particularly at low signal levels. Additionally, U(t) oscillation was lower in frequency at all click intensities following noise exposure. N increased with signal level and was smaller after noise exposure at the lowest signal level. Collectively these findings indicate that neurons contributing to the CAP during TTS are fewer in number, shorter in latency, and poorer in synchrony than before noise exposure. Moreover, estimates of single neuron action potentials may decay more rapidly and have a lower oscillatory frequency during TTS. PMID:18397026

Phase correlated adequate afferent action potentials as a drive of human spinal oscillators.

PubMed

Schalow, G

1993-12-01

1. By recording, with 2 pairs of wire electrodes, single-fibre action potentials (APs) from lower sacral nerve roots of a brain-dead human and a patient with spinal cord lesion, impulse patterns of afferent APs and impulse trains of oscillatory firing motoneurons could be identified and correlated. 2. Two highly activated secondary muscle spindle afferents increased and decreased their activity at about 0.3 Hz. The duration of the doublet interspike interval of a secondary spindle afferent fibre showed no correlation to the oscillation period of the motoneuron. 3. A continuously oscillatory firing motoneuron innervating the external and sphincter showed more transient breaks with the reduction of the number of phase correlated APs from 2 spindle afferents, indicating a looser oscillation. A transient brake of a 157 msec period alpha 2-oscillation could be correlated to the shift of a interspike interval distribution peak from 150 to 180 msec of the adequate afferent input, which suggests a transient loss of the necessary phase relation. 4. Oscillatory firing alpha 2-motoneurons innervating the external bladder and anal sphincters fired independently according to their phase correlated APs from the urinary bladder stretch receptor and muscle spindle afferents respectively; the bladder motoneuron slightly inhibited the anal motoneuron. 5. Receptors of the afferents and innervation sites of oscillatory firing motoneurons could be located within the urinary tract and the anal canal.

[Anatomy and physiology of sexuality].

PubMed

Cour, F; Droupy, S; Faix, A; Methorst, C; Giuliano, F

2013-07-01

Knowledge of the physiology of male and female sexuality has advanced considerably. Initially there is always desire with its biological neuroendocrine components and its emotional field which is particularly marked in women. There is a distinction between "spontaneous" sexual desire related to intrinsic affective, cognitive stimuli, and fantasies, and "reactive" sexual desire in response to physical arousal. There are similarities between men and women concerning the activation of cerebral zones in sexual arousal contexts in laboratory conditions. The neural pathways for sexual arousal are similar between men and women, bringing into play the sympathetic centres of the thoracic and lumbar spinal cord and, at the sacral level, the parasympathetic center and the motoneurons controlling the muscular contractions of the pelviperineal striated muscles. Genital sensitivity is mainly transmitted by the pudendal nerve in both men and women. Sexual arousal in men consists of penile erection, and ejaculation accompanied with orgasm. In women, sexual arousal causes increase in blood to flow to the vagina leading to lubrication and to the vulva leading to the erection of the clitoris and vulvar hyperaemia. The orgasm which can be multiple in women is accompanied by contractions of the striated perineal muscles. Several neurotransmitters are closely involved in the control of sexuality at the central level: dopamine, ocytocin, serotonin, and peripheral: nitric oxide and noradrenaline in men, vasoactive intestinal peptide and neuropeptide Y in women. Copyright © 2012. Published by Elsevier Masson SAS.

[Lower urinary tract dysfunction in normal pressure hydrocephalus: Review of the literature].

PubMed

Bey, E; Nicot, B; Casez, O; Le Normand, L

2016-12-01

Lower urinary tract dysfunction in normal pressure hydrocephalus has received little attention from the scientific community. The aim of this review article was to discuss diagnostic and therapeutic options for these patients. A literature review of MedLine publications on urinary incontinence in normal pressure hydrocephalus was conducted. The following keywords were used: "hydrocephalus, normal pressure" and "bladder dysfunction" or "urinary incontinence" or "overactive bladder" or "urinary bladder, neurogenic". Prospective and retrospective studies as well as previous reviews were analyzed. Urinary symptoms in normal pressure hydrocephalus are mainly represented by overactive bladder, which is a significant burden for the concerned patients. Isolated overactive bladder is more frequent (64%) than urinary incontinence (57%). Detrusor overactivity is seen in 95.2% of the cases. Neuro-surgery is efficient on urinary symptoms for 61.5% of the patients. Bladder recovery after surgery relates with increased mid-cingulate perfusion, probably linked with a functional restoration of the mid-cingulate that normally inhibits the micturition reflex. Medical options, added or not to surgery, include anticholinergic drugs unable to pass through the blood-brain barrier, Transcutaneous Electrical Nerve Stimulation and sacral neuromodulation. There is actually an insufficient concern about urinary symptoms in normal pressure hydrocephalus. This article highlights the importance of a harmonization of neuro-urological practices in the pre-therapeutic evaluation of patients suffering from normal pressure hydrocephalus. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

A problematic early tetrapod from the Mississippian of Nevada

USGS Publications Warehouse

Thomson, K.S.; Shubin, N.S.; Poole, F.G.

1998-01-01

We report here the discovery of a new taxon of Paleozoic tetrapod from the Late Mississippian of Nevada (330-340 Ma). It has a unique vertebral column with principal centra having vertical anterior and posterior faces, ventrally incomplete accessory centra located antero-dorsally in each centrum, and enlarged presacral/sacral vertebrae. The head and pectoral girdle were not preserved but the large femur, robust pelvic girdle and enlarged sacral vertebrae possibly indicate a terrestrial mode of life. This new form significantly extends the western geographic range of known Mississippian tetrapods. It presents a mosaic of primitive and derived features, indicating that continued revision of traditional accounts of vertebral homology and the early diversifications of Paleozoic tetrapods will be necessary.

Caudal dysgenesis in islet-1 transgenic mice

PubMed Central

Muller, Yunhua Li; Yueh, Yir Gloria; Yaworsky, Paul J.; Salbaum, J. Michael; Kappen, Claudia

2014-01-01

Maternal diabetes during pregnancy is responsible for the occurrence of diabetic embryopathy, a spectrum of birth defects that includes heart abnormalities, neural tube defects, and caudal dysgenesis syndromes. Here, we report that mice transgenic for the homeodomain transcription factor Isl-1 develop profound caudal growth defects that resemble human sacral/caudal agenesis. Isl-1 is normally expressed in the pancreas and is required for pancreas development and endocrine cell differentiation. Aberrant regulation of this pancreatic transcription factor causes increased mesodermal cell death, and the severity of defects is dependent on transgene dosage. Together with the finding that mutation of the pancreatic transcription factor HLXB9 causes sacral agenesis, our results implicate pancreatic transcription factors in the pathogenesis of birth defects associated with diabetes. PMID:12738808

The role of rigid vs. dynamic instrumentation for stabilization of the degenerative lumbosacral spine.

PubMed

Korovessis, Panagiotis; Papazisis, Zisis; Lambiris, Elias

2002-01-01

This is a prospective comparative randomised study to compare the immediately postoperative effects of a rigid versus dynamic instrumentation for degenerative spine disease and stenosis on the standing sagittal lumbar spine alignment and to investigate if a dynamic spine system can replace the commonly used rigid systems in order to avoid the above mentioned disadvantages of rigid fixation. 15 randomly selected patients received the rigid instrumentation SCS and an equal number of randomly selected patients the dynamic TWINFLEX device for spinal stenosis associated degenerative lumbar disease. The age of the patients, who received rigid and dynamic instrumentation was 65 +/- 9 years and 62 +/- 10 years respectively. All patients had standing spine radiographs preoperatively and three months postoperatively. The parameters that were measured and compared pre- to postoperatively were: lumbar lordosis (L1-S1), total lumbar lordosis (T12-S1), sacral tilt, distal lordosis (L4-S1), intervertebral angulation, vertebral inclination and disc index. The instrumented levels in the spines that received rigid and dynamic instrumentation were 3.5 +/- 0.53 and 3 +/- 0.7 respectively. The instrumented levels from L3 to L5 were 23, the lumbosacral junction was instrumented in 3 patients of group A and in 4 patients of group B. Lumbar lordosis did not significantly change postoperatively, while total lordosis was significantly (P=0.04) increased in the patients who received the rigid instrumentation, while it was significantly (P=0.012) decreased in the group B. Intervertebral angulation of the non-instrumented level L1-L2 was increased in the group A (P=0.01), while the dynamic instrumentation increased (P=0.02) the intervertebral inclination of the adjacent level L2-L3, immediately above the uppermost instrumented level. Distal lordosis and sacral tilt did not change in any patient in both groups. Both instrumentations did not change the lateral vertebral inclination of L1 to L5 vertebrae. Rigid instrumentation increased the lordotic inclination of L5 (P=0.03) and of S1 (P=0.03). Rigid instrumentation increased (P=0.04) the intervertebral angulation at the uppermost instrumented level L3-L4 The most significant change in vertebral angulation was achieved at the instrumented level L4-L5 by the dynamic (P=0.007) and rigid (0.05). The disc index at the level L2-L3 was increased by both instrumentation [dynamic P=0.007 and rigid (P=0.02)]. The index L3-L4 was increased following dynamic fixation (P=0.0007). The disc index L4-L5 was postoperatively increased by both types of instrumentation (rigid P=0.006, dynamic P=0.02). The disc index L5-S1 did not significantly change postoperatively by either system. Both rigid and dynamic instrumentations restored lumbar lordosis, sacral tilt, distal lordosis and increased the foraminal diameter at the level L4-L5 resulting in an indirect decompression of the nerve roots at this level . Both rigid and dynamic instrumentations applied in the lumbosacral spine to treat degenerative disease secured L3 to S1 sagittal spine profile close to preoperative levels, that should theoretically guarantee a pain-free postoperative course. This study supports the belief that the dynamic system can be used with the same indications with the rigid in degenerative lumbar spine because it can offer equally good short-term results regarding sagittal spine alignment while simultaneously it has the previously mentioned advantages (avoidance stress shielding etc).

Delayed Union of a Sacral Fracture: Percutaneous Navigated Autologous Cancellous Bone Grafting and Screw Fixation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Huegli, R. W.; Messmer, P.; Jacob, A. L.

2003-09-15

Delayed or non-union of a sacral fracture is a serious clinical condition that may include chronic pain, sitting discomfort, gait disturbances, neurological problems, and inability to work. It is also a difficult reconstruction problem. Late correction of the deformity is technically more demanding than the primary treatment of acute pelvic injuries. Open reduction, internal fixation (ORIF), excision of scar tissue, and bone grafting often in a multi-step approach are considered to be the treatment of choice in delayed unions of the pelvic ring. This procedure implies the risk of neurological and vascular injuries, infection, repeated failure of union, incomplete correctionmore » of the deformity, and incomplete pain relief as the most important complications. We report a new approach for minimally invasive treatment of a delayed union of the sacrum without vertical displacement. A patient who suffered a Malgaigne fracture (Tile C1.3) was initially treated with closed reduction and percutaneous screw fixation (CRPF) of the posterior pelvic ring under CT navigation and plating of the anterior pelvic ring. Three months after surgery he presented with increasing hip pain caused by a delayed union of the sacral fracture. The lesion was successfully treated percutaneously in a single step procedure using CT navigation for drilling of the delayed union, autologous bone grafting, and screw fixation.« less

Evidence that the notochord may be pivotal in the development of sacral and anorectal malformations.

PubMed

Qi, Bao Quan; Beasley, Spencer W; Frizelle, Francis A

2003-09-01

The notochord is known to organize normal development of central axial structures, such as the spinal cord, vertebral column, and anorectum, but its role in abnormal development of these organs has not been well documented. The current study has used Ethylenethiourea to induce anorectal malformations in fetal rats, allowing investigation of abnormalities of the notochord and their relationship to the axial structural abnormalities that occur. Timed-mated pregnant rats were fed Ethylenethiourea by gavage on gestational day 10. Their embryos were harvested on gestational days 13 to 16 and sectioned in either the transverse or sagittal plane. Sections were stained with H and E and examined serially. Anorectal malformations were identified in 29 of 34 embryos and neural tube defects in 24, ranging from an accessory neural tube to lumbo-sacral rachischisis. There was no tail or only a rudimentary tail in the majority of embryos. Abnormalities of the notochord in the lumbo-sacral area included ventro-dorsal branching, ventral deviation, and ectopic notochordal tissue. Most abnormal notochord branches and ectopic notochordal tissue were abnormally close to or in contact with the wall of the cloaca or neural tube. Given the known role of the notochord in controlling normal development, this study would suggest that abnormal notochord development may be pivotal in producing neural tube defects and anorectal malformations, possibly by altering sonic hedgehog signalling.

Combined V-Y Fasciocutaneous Advancement and Gluteus Maximus Muscle Rotational Flaps for Treating Sacral Sores

PubMed Central

Choi, Eun Jeong; Moon, Suk Ho; Lee, Yoon Jae

2016-01-01

The sacral area is the most common site of pressure sore in bed-ridden patients. Though many treatment methods have been proposed, a musculocutaneous flap using the gluteus muscles or a fasciocutaneous flap is the most popular surgical option. Here, we propose a new method that combines the benefits of these 2 methods: combined V-Y fasciocutaneous advancement and gluteus maximus muscle rotational flaps. A retrospective review was performed for 13 patients who underwent this new procedure from March 2011 to December 2013. Patients' age, sex, accompanying diseases, follow-up duration, surgical details, complications, and recurrence were documented. Computed tomography was performed postoperatively at 2 to 4 weeks and again at 4 to 6 months to identify the thickness and volume of the rotational muscle portion. After surgery, all patients healed within 1 month; 3 patients experienced minor complications. The average follow-up period was 13.6 months, during which time 1 patient had a recurrence (recurrence rate, 7.7%). Average thickness of the rotated muscle was 9.43 mm at 2 to 4 weeks postoperatively and 9.22 mm at 4 to 6 months postoperatively (p = 0.087). Muscle thickness had not decreased, and muscle volume was relatively maintained. This modified method is relatively simple and easy for reconstructing sacral sores, provides sufficient padding, and has little muscle donor-site morbidity. PMID:27366755

Objective evaluation by reflectance spectrophotometry can be of clinical value for the verification of blanching/non blanching erythema in the sacral area.

PubMed

Sterner, Eila; Fossum, Bjöörn; Berg, Elisabeth; Lindholm, Christina; Stark, André

2014-08-01

Early detection of non blanching erythema (pressure ulcer category I) is necessary to prevent any further skin damage. An objective method to discriminate between blanching/non blanching erythema is presently not available. The purpose of this investigation was to explore if a non invasive objective method could differentiate between blanching/non blanching erythema in the sacral area of patients undergoing hip fracture surgery. Seventy-eight patients were included. The sacral area of all patients was assessed using (i) conventional finger-press test and (ii) digital reading of the erythema index assessed with reflectance spectrophotometry. The patients were examined at admission and during 5 days postsurgery. Reflectance spectrophotometry measurements proved able to discriminate between blanching/non blanching erythema. The reliability, quantified by the intra-class correlation coefficient, was excellent between repeated measurements over the measurement period, varying between 0·82 and 0·96, and a significant change was recorded in the areas from day 1 to day 5 (P < 0·0001). The value from the reference point did not show any significant changes over the same period (P = 0·32). An objective method proven to identify early pressure damage to tissue can be a valuable tool in clinical practice. © 2013 The Authors. International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

[Effectiveness of Sacral Intervertebral Epidural Block for Umbilical Hernia Repair in Children].

PubMed

Nagamine, Norimitsu; Furuya, Atsushi; Suzuki, Sho; Kondo, Satoko; Kiuchi, Riko; Suzuki, Satomi; Nonaka, Akihiko

2015-02-01

Effectiveness of sacral intervertebral epidural block (S 2-3 block) for umbilical hernia repair has not been clarified. We investigate 24 children, undergoing umbilical hernia repair; mean age of 3 years (age range: 20-65 months). Under general anesthesia, epidural block was performed at S 2-3 interspace with 1 ml x kg(-1) ropivacaine (0.2%) at injecting rate of 1 ml x sec(-1) followed by 0.25 ml x kg(-1) normal saline. In all cases, neither systolic blood pressure nor heart rate increased > 15% from those just before the block. Postoperative analgesics were given in 6 patients (25%) rectally. Mean time between the block and the administration of analgesic was 10.5 hours. S 2-3 block can be effective for postoperative pain in umbilical hernia repair.

Reflex respiratory and cardiovascular effects of stimulation of receptors in the nose of the dog.

PubMed

James, J E; De Burgh Daly, M

1972-02-01

1. In forty-one out of forty-seven dogs under chloralose-urethane or Nembutal anaesthesia, mechanical stimulation of the nasal mucous membrane caused a reduction or inhibition of respiration, bradycardia, variable changes of arterial blood pressure, and a small rise in venous pressure.2. Simultaneous measurements of arterial and venous pressures, and also of blood flow in various arteries by means of an electromagnetic flowmeter indicate that the calculated vascular resistance increases in the intact limb, muscle, and skin, and the vascular beds of the vertebral, superior mesenteric, renal and splenic arteries. No changes in vascular resistance occur in the common carotid circulation.3. Evidence is presented that the increase in vascular resistance is due to vasoconstriction, and occurs in the absence of changes in pulmonary ventilation.4. Stimulation of the nasal mucous membrane causes a reduction in volume of the spleen.5. The respiratory and cardiovascular responses are reflex in nature, being abolished by the application of a local anaesthetic to the nose or by combined division of the maxillary and ethmoidal branches of the trigeminal nerves. The cardiac response is mediated largely by the vagus nerves, and the vascular responses by sympathetic adrenergic fibres.6. Cessation of the stimulus to the nose not infrequently results in the following temporary after-effects: hyperventilation, tachycardia, hypertension, and vasodilatation in the intact limb and in muscle.

Spinal cord stimulation for treatment of meralgia paresthetica.

PubMed

Barna, Steven A; Hu, M Melvin; Buxo, Carlos; Trella, Jason; Cosgrove, G Rees

2005-07-01

Meralgia paresthetica is a clinical syndrome of pain, dysesthesia or both, in the anterolateral thigh. It is associated with an entrapment mononeuropathy of the lateral femoral cutaneous nerve. Diagnosis of meralgia paresthetica is typically made clinically and is based on the characteristic location of pain or dysesthesia, sensory abnormality on exam, and absence of any other neurological abnormality in the leg. The majority of patients with meralgia paresthetica respond well to conservative treatment. To present a case of intractable meralgia paresthetica in which conservative treatment options failed but which was successfully treated with a spinal cord stimulator. A 44-year-old woman presented to the pain clinic with a one-year history of bilateral anterolateral thigh pain. History, physical exam, and diagnostic work-up were consistent with meralgia paresthetica. Multiple medications, physical therapy, and chiropractic therapy were not successful for this patient. In addition, local anesthetic/steroid injection of the lateral femoral cutaneous nerve provided only short-term relief. Ultimately, a spinal cord stimulator was implanted after a successful temporary percutaneous trial. Two months after the implantation, she continued to have 100% pain relief, worked full-time, was physically active, and no longer required any pain medication including opioids. An implanted spinal cord stimulator may be an ideal treatment for intractable meralgia paresthetica after conservative treatments have failed because it is not destructive and can always be explanted without significant permanent adverse effects.

Beads but no collar; the significance of an asymptomatic rib bone healing pattern in infants.

PubMed

Talbert, David

2010-07-01

When a long bone, such as a rib, is broken, the position of the break can be seen in the following weeks by a temporary collar of a collagen based material (callus) which holds the broken ends together during the repair process. However in infants a different pattern is sometimes found at autopsy, in which the repair material occurs as widely spaced "beads" along the shaft of the rib. The consistency of the bead material corresponds to the progress of repair in the normal way, but there is no focal region as would be expected in a clean break or greenstick fracture. It is proposed that this results from micro-fractures in the compact bone forming the outer aspect of the rib when it is bent excessively, during thoracic compression such as required in Cardiopulmonary Resuscitation, (CPR), or when the infant is "grabbed" when about to slip from the hands of a carer. The compact bone surface is covered by a relatively very elastic layer, the periosteum, which carries nerves sensitive to stretch or tearing of this periosteum. It is proposed that the local stretch induced in the periosteum bridging these micro-fractures is insufficient to cause these nerves to signal pain and so the condition is asymptomatic, and may be quite common in infancy. It should not be confused with imposed trauma. Copyright 2010 Elsevier Ltd. All rights reserved.

Comparison of Lumbar Lordosis in Lateral Radiographs in Standing Position with supine MR Imaging in consideration of the Sacral Slope.

PubMed

Benditz, Achim; Boluki, Daniel; Weber, Markus; Zeman, Florian; Grifka, Joachim; Völlner, Florian

2017-03-01

Purpose  To investigate the influence of sacral slope on the correlation between measurements of lumbar lordosis obtained by standing radiographs and magnetic resonance images in supine position (MRI). Little information is available on the correlation between measurements of lumbar lordosis obtained by radiographic and MR images. Most relevant studies have shown correlations for the thoracic spine, but detailed analyses on the lumbar spine are lacking. Methods  MR images and standing lateral radiographs of 63 patients without actual low back pain or radiographic pathologies of the lumbar spine were analyzed. Standing radiographic measurements included the sagittal parameters pelvic incidence (PI) pelvic tilt (PT), and sacral slope (SS); MR images were used to additionally measure lumbar L1-S1 lordosis and single level lordosis. Differences between radiographic and MRI measurements were analyzed and divided into 4 subgroups of different sacral slope according to Roussouly's classification. Results  Global lumbar lordosis (L1-S1) was 44.99° (± 10 754) on radiographs and 47.91° (± 9.170) on MRI, yielding a clinically relevant correlation (r = 0.61, p < 0.01). Measurements of single level lordosis only showed minor differences. At all levels except for L5 / S1, lordosis measured by means of standing radiographs was higher than that measured by MRI. The difference in global lumbar L1-S1 lordosis was -2.9°. Analysis of the Roussouly groups showed the largest difference for L1-S1 (-8.3°) in group 2. In group 4, when measured on MRI, L5 / S1 lordosis (25.71°) was lower than L4 / L5 lordosis (27.63°) compared to the other groups. Conclusions  Although measurements of global lumbar lordosis significantly differed between the two scanning technologies, the mean difference was just 2.9°. MRI in supine position may be used for estimating global lumbar lordosis, but single level lordosis should be determined by means of standing radiographs. Key Points   · Large difference between radiographic and MRI measurements of level L5 / S1.. · MRI can be used for estimating global lumbar lordosis.. · Analysis of single level lordosis necessitates measurement in standing radiographs.. Citation Format · Benditz A, Boluki D, Weber M et al. Comparison of Lumbar Lordosis in Lateral Radiographs in Standing Position with supine MR Imaging in consideration of the Sacral Slope. Fortschr Röntgenstr 2017; 189: 233 - 239. © Georg Thieme Verlag KG Stuttgart · New York.

Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis.

PubMed

Smith, J A; Deviren, V; Berven, S; Kleinstueck, F; Bradford, D S

2001-10-15

A clinical retrospective study was conducted. To evaluate the clinical and radiographic outcome of reduction followed by trans-sacral interbody fusion for high-grade spondylolisthesis. In situ posterior interbody fusion with fibula allograft has improved the fusion rates for patients with high-grade spondylolisthesis. The use of this technique in conjunction with partial reduction has not been reported. Nine consecutive patients underwent treatment of high-grade (Grade 3 or 4) spondylolisthesis with partial reduction followed by posterior interbody fusion using cortical allograft. The average age at the time of surgery was 27 years (range, 8-51 years), and the average follow-up period was 43 months (range, 24-72 months). Before surgery, eight patients had low back pain, seven patients had radiating leg pain, and five patients had hamstring tightness. The average grade of spondylolisthesis by Meyerding grading was 3.9 (range, 3-5). Charts and radiographs were evaluated, and outcomes were collected by use of the modified SRS outcomes instrument. Radiographic indexes demonstrated significant improvement with partial reduction and fusion. The slip angle, as measured from the inferior endplate of L5, improved from 41.2 degrees (range, 24-82 degrees ) before surgery to 21 degrees (range, 5-40 degrees ) after surgery. All the patients were extremely or somewhat satisfied with surgery. The two patients who underwent this operation without initial instrumentation experienced fractures of their interbody grafts. Both of these patients underwent repair of the pseudarthrosis with placement of trans-sacral pedicle screw instrumentation and subsequent fusion. Partial reduction followed by posterior interbody fusion is an effective technique for the management of high-grade spondylolisthesis in pediatric and adult patient populations, as assessed by radiographic and clinical criteria. Pedicle screw instrumentation with the sacral screws capturing L5 is recommended when this technique is used for the treatment of high-grade spondylolisthesis. According to the clinical and radiographic results from this study, partial reduction and posterior fibula interbody fusion supplemented with pedicle screw instrumentation is an effective technique for select patients with high-grade spondylolisthesis at L5-S1.

Mechanical comparison between lengthened and short sacroiliac screws in sacral fracture fixation: a finite element analysis.

PubMed

Zhao, Y; Zhang, S; Sun, T; Wang, D; Lian, W; Tan, J; Zou, D; Zhao, Y

2013-09-01

To compare the stability of lengthened sacroiliac screw and standard sacroiliac screw for the treatment of unilateral vertical sacral fractures; to provide reference for clinical applications. A finite element model of Tile type C pelvic ring injury (unilateral Denis type II fracture of the sacrum) was produced. The unilateral sacral fractures were fixed with lengthened sacroiliac screw and sacroiliac screw in six different types of models respectively. The translation and angle displacement of the superior surface of the sacrum (in standing position on both feet) were measured and compared. The stability of one lengthened sacroiliac screw fixation in S1 or S2 segment is superior to that of one sacroiliac screw fixation in the same sacral segment. The stability of one lengthened sacroiliac screw fixation in S1 and S2 segments respectively is superior to that of one sacroiliac screw fixation in S1 and S2 segments respectively. The stability of one lengthened sacroiliac screw fixation in S1 and S2 segments respectively is superior to that of one lengthened sacroiliac screw fixation in S1 or S2 segment. The stability of one sacroiliac screw fixation in S1 and S2 segments respectively is markedly superior to that of one sacroiliac screw fixation in S1 or S2 segment. The vertical and rotational stability of lengthened sacroiliac screw fixation and sacroiliac screw fixation in S2 is superior to that of S1. In a finite element model of type C pelvic ring disruption, S1 and S2 lengthened sacroiliac screws should be utilized for the fixation as regularly as possible and the most stable fixation is the combination of the lengthened sacroiliac screws of S1 and S2 segments. Even if lengthened sacroiliac screws cannot be systematically used due to specific conditions, one sacroiliac screw fixation in S1 and S2 segments respectively is recommended. No matter which kind of sacroiliac screw is used, if only one screw can be implanted, the fixation in S2 segment is more recommended than that in S1. Experimental study Level III. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Microcirculatory responses of sacral tissue in healthy individuals and inpatients on different pressure-redistribution mattresses.

PubMed

Bergstrand, S; Källman, U; Ek, A-C; Engström, M; Lindgren, M

2015-08-01

The aim of this study was to explore the interaction between interface pressure, pressure-induced vasodilation, and reactive hyperaemia with different pressure-redistribution mattresses. A cross-sectional study was performed with a convenience sample of healthy young individuals, and healthy older individuals and inpatients, at a university hospital in Sweden. Blood flow was measured at depths of 1mm, 2mm, and 10mm using laser Doppler flowmetry and photoplethysmography. The blood flow, interface pressure and skin temperature were measured in the sacral tissue before, during, and after load while lying on one standard hospital mattress and three different pressure-redistribution mattresses. There were significant differences between the average sacral pressure, peak sacral pressure, and local probe pressure on the three pressure-redistribution mattresses, the lowest values found were with the visco-elastic foam/air mattress (23.5 ± 2.5mmHg, 49.3 ± 11.1mmHg, 29.2 ± 14.0mmHg, respectively). Blood flow, measured as pressure-induced vasodilation, was most affected in the visco-elastic foam/air group compared to the alternating pressure mattress group at tissue depths of 2mm (39.0% and 20.0%, respectively), and 10mm (56.9 % and 35.1%, respectively). Subjects in all three groups, including healthy 18-65 year olds, were identified with no pressure-induced vasodilation or reactive hyperaemia on any mattress (n=11), which is considered a high-risk blood flow response. Interface pressure magnitudes considered not harmful during pressure-exposure on different pressure-redistribution mattresses can affect the microcirculation in different tissue structures. Despite having the lowest pressure values compared with the other mattresses, the visco-elastic foam/air mattress had the highest proportion of subjects with decreased blood flow. Healthy young individuals were identified with the high-risk blood flow response, suggesting an innate vulnerability to pressure exposure. Furthermore, the evaluation of pressure-redistribution support surfaces in terms of mean blood flow during and after tissue exposure is not feasible, but assessment of pressure-induced vasodilation and reactive hyperaemia could be a new way to assess individualised physiological measurements of mechanisms known to be related to pressure ulcer development.

Psoas compartment and sacral plexus block via electrostimulation for pelvic limb amputation in dogs.

PubMed

Congdon, Jonathon M; Boscan, Pedro; Goh, Clara S S; Rezende, Marlis

2017-07-01

To assess the efficacy of psoas compartment and sacral plexus block for pelvic limb amputation in dogs. Prospective clinical study. A total of 16 dogs aged 8±3 years and weighing 35±14 kg (mean±standard deviation). Dogs were administered morphine (0.5 mg kg -1 ) and atropine (0.02 mg kg -1 ); anesthesia was induced with propofol and maintained with isoflurane. Regional blocks were performed before surgery in eight dogs with bupivacaine (2.2 mg kg -1 ) and eight dogs were administered an equivalent volume of saline. The lumbar plexus within the psoas compartment was identified using electrolocation lateral to the lumbar vertebrae at the fourth-fifth, fifth-sixth and sixth-seventh vertebral interspaces. The sacral plexus, ventrolateral to the sacrum, was identified using electrolocation. Anesthesia was monitored using heart rate (HR), invasive blood pressure, electrocardiography, expired gases, respiratory frequency and esophageal temperature by an investigator unaware of the group allocation. Pelvic limb amputation by coxofemoral disarticulation was performed. Dogs that responded to surgical stimulation (>10% increase in HR or arterial pressure) were administered fentanyl (2 μg kg -1 ) intravenously for rescue analgesia. Postoperative pain was assessed at extubation; 30, 60 and 120 minutes; and the morning after surgery using a visual analog scale (VAS). The number of intraoperative fentanyl doses was fewer in the bupivacaine group (2.7±1.1 versus 6.0±2.2; p<0.01). Differences in physiologic variables were not clinically significant. VAS scores were lower in bupivacaine dogs at extubation (0.8±1.9 versus 3.8±2.5) and at 30 minutes (1.0±1.4 versus 4.3±2.1; p<0.05). Psoas compartment (lumbar plexus) and sacral plexus block provided analgesia during pelvic limb amputation in dogs. Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

Investigating the role of capacitive coupling between the operating table and the return electrode of an electrosurgery unit in the modification of the current density distribution within the patients' body.

PubMed

Bifulco, Paolo; Massa, Rita; Cesarelli, Mario; Romano, Maria; Fratini, Antonio; Gargiulo, Gaetano D; McEwan, Alistair L

2013-08-12

Electrosurgery units are widely employed in modern surgery. Advances in technology have enhanced the safety of these devices, nevertheless, accidental burns are still regularly reported. This study focuses on possible causes of sacral burns as complication of the use of electrosurgery. Burns are caused by local densifications of the current, but the actual pathway of current within patient's body is unknown. Numerical electromagnetic analysis can help in understanding the issue. To this aim, an accurate heterogeneous model of human body (including seventy-seven different tissues), electrosurgery electrodes, operating table and mattress was build to resemble a typical surgery condition. The patient lays supine on the mattress with the active electrode placed onto the thorax and the return electrode on his back. Common operating frequencies of electrosurgery units were considered. Finite Difference Time Domain electromagnetic analysis was carried out to compute the spatial distribution of current density within the patient's body. A differential analysis by changing the electrical properties of the operating table from a conductor to an insulator was also performed. Results revealed that distributed capacitive coupling between patient body and the conductive operating table offers an alternative path to the electrosurgery current. The patient's anatomy, the positioning and the different electromagnetic properties of tissues promote a densification of the current at the head and sacral region. In particular, high values of current density were located behind the sacral bone and beneath the skin. This did not occur in the case of non-conductive operating table. Results of the simulation highlight the role played from capacitive couplings between the return electrode and the conductive operating table. The concentration of current density may result in an undesired rise in temperature, originating burns in body region far from the electrodes. This outcome is concordant with the type of surgery-related sacral burns reported in literature. Such burns cannot be immediately detected after surgery, but appear later and can be confused with bedsores. In addition, the dosimetric analysis suggests that reducing the capacity coupling between the return electrode and the operating table can decrease or avoid this problem.

A New Radiofrequency Ablation Procedure to Treat Sacroiliac Joint Pain.

PubMed

Cheng, Jianguo; Chen, See Loong; Zimmerman, Nicole; Dalton, Jarrod E; LaSalle, Garret; Rosenquist, Richard

2016-01-01

Low back pain may arise from disorders of the sacroiliac joint in up to 30% of patients. Radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint has been shown to be a safe and efficacious strategy. We aimed to develop a new RFA technique to relieve low back pain secondary to sacroiliac joint disorders. Methodology development with validation through prospective observational non-randomized trial (PONRT). Academic multidisciplinary health care system, Ohio, USA. We devised a guide-block to facilitate accurate placement of multiple electrodes to simultaneously ablate the L5 dorsal ramus and lateral branches of the S1, S2, and S3 dorsal rami. This was achieved by bipolar radiofrequency ablation (b-RFA) to create a strip lesion from the lateral border of the base of the sacral superior articular process (L5-S1 facet joint) to the lateral border of the S3 sacral foramen. We applied this technique in 31 consecutive patients and compared the operating time, x-ray exposure time and dose, and clinical outcomes with patients (n = 62) who have been treated with the cooled radiofrequency technique. Patients' level of pain relief was reported as < 50%, 50 - 80%, and > 80% pain relief at one, 3, 6, and 12 months after the procedure. The relationship between RFA technique and duration of pain relief was evaluated using interval-censored multivariable Cox regression. The new technique allowed reduction of operating time by more than 50%, x-ray exposure time and dose by more than 80%, and cost by more than $1,000 per case. The percent of patients who achieved > 50% pain reduction was significantly higher in the b-RFA group at 3, 6, and 12 months follow-up, compared to the cooled radiofrequency group. No complications were observed in either group. Although the major confounding factors were taken into account in the analysis, use of historical controls does not balance observed and unobserved potential confounding variables between groups so that the reported results are potentially confounded. Compared to the cooled radiofrequency ablation (c-RFA) technique, the new b-RFA technique reduced operating time by more than 50%, decreased x-ray exposure by more than 80%, and cut the cost by more than $1000 per case. The new method was associated with significantly improved clinical outcomes despite the limitations of the study design. Thus this new technique appeared to be safe, efficacious, and cost-effective. Key words: Sacroiliac joint pain, sacroiliac joint, low back pain, radiofrequency ablation (RFA), bipolar radiofrequency ablation (b-RFA), cooled radiofrequency ablation (c-RFA), cost-effectiveness.

Targeted, noninvasive blockade of cortical neuronal activity

NASA Astrophysics Data System (ADS)

McDannold, Nathan; Zhang, Yongzhi; Power, Chanikarn; Arvanitis, Costas D.; Vykhodtseva, Natalia; Livingstone, Margaret

2015-11-01

Here we describe a novel method to noninvasively modulate targeted brain areas through the temporary disruption of the blood-brain barrier (BBB) via focused ultrasound, enabling focal delivery of a neuroactive substance. Ultrasound was used to locally disrupt the BBB in rat somatosensory cortex, and intravenous administration of GABA then produced a dose-dependent suppression of somatosensory-evoked potentials in response to electrical stimulation of the sciatic nerve. No suppression was observed 1-5 days afterwards or in control animals where the BBB was not disrupted. This method has several advantages over existing techniques: it is noninvasive; it is repeatable via additional GABA injections; multiple brain regions can be affected simultaneously; suppression magnitude can be titrated by GABA dose; and the method can be used with freely behaving subjects. We anticipate that the application of neuroactive substances in this way will be a useful tool for noninvasively mapping brain function, and potentially for surgical planning or novel therapies.

Transient urinary retention and chronic neuropathic pain associated with genital herpes simplex virus infection.

PubMed

Haanpää, Maija; Paavonen, Jorma

2004-10-01

Genital herpes (GH) causes genital ulcer disease, severe transient pain, and often paresthesias. Whether or not GH can cause urinary retention or chronic neuropathic pain is not well known. We present two immunocompetent patients with GH associated with neuropathic symptoms. We also review the literature on GH and associated neurologic problems. Patient 1 had primary herpes simplex virus (HSV)-2 infection with transient urinary retention and chronic bilateral neuropathic pain in the sacral area. Patient 2 had recurrent HSV-1 associated with unitaleral chronic neuropathic pain in the sacral area. Although transient urinary retention associated with GH is not uncommon, chronic neuropathic pain has not been reported previously. Our cases show that chronic neuropathic pain, that is "pain initiated or caused by a primary lesion or dysfunction in the nervous system," can follow genital HSV infection.

Refined localization of the Prieto-syndrome locus

DOE Office of Scientific and Technical Information (OSTI.GOV)

Martinez, F.; Prieto, F.; Gal, A.

PRS designates the locus for a syndromal form of X-linked mental retardation (Prieto syndrome) characterized by minor facial anomalies, ear malformation, abnormal growth of teeth, clinodactyly, sacral dimple, patellar luxation, malformation of lower limbs, abnormalities of the fundus of the eye, and subcortical cerebral atrophy. Linkage analysis localized the disease locus between DXS84 (Xp21.1) and DXS255. Here we present additional linkage data that provide further support and refinement of this localization. Individual III-18 gave birth to a male, currently aged 2 7/12 years, who clearly shows delayed psychomotor development. He began to walk at 23 months and his speech ismore » delayed. In addition, he shows the characteristic facial anomalies, {open_quotes}dysplastic{close_quotes} ears, sacral dimple, and clinodactyly, as do all other affected males in this family. 7 refs., 1 tab.« less

Transient paraplegia due to accidental intrathecal bupivacaine infiltration following pre-emptive analgesia in a patient with missed sacral dural ectasia.

PubMed

Kanna, P Rishimugesh; Sekar, Chelliah; Shetty, Ajoy Prasad; Rajasekaran, Shanmughanathan

2010-11-15

A case report with review of the literature. To highlight the need for careful magnetic resonance imaging evaluation for the presence of incidental lumbosacral dural anomalies before attempting caudal epidural interventions. Pre-emptive analgesia through the caudal epidural route provides good postoperative pain relief in spine surgeries. Several precautions have been advised in the literature. Presence of sacral-dural ectasia should be considered a relative contraindication for this procedure. A 50-year old woman underwent posterior instrumented spinal fusion for L4-L5 spondylolisthesis under general anesthesia. She received single shot caudal epidural analgesia at the start of the procedure. After complete emergence from anesthesia, she had complete motor and sensory loss below the T12 spinal level, which reversed to normal neurology in 6 hours. Retrospective evaluation of the patient's magnetic resonance imaging showed an ectatic, low lying lumbosacral dural sac which had been overlooked in the initial evaluation. The drugs given by the caudal route have been accidentally administered into the thecal sac causing a brief period of neurologic deficit. This unexpected complication has been reported only in the pediatric literature before. It is important to look for the presence of lumbosacral dural anomalies before planning caudal epidural injections in adults also. Sacral dural ectasia and other lumbosacral anomalies must be recognized as contraindications for caudal epidural pre-emptive analgesia for spine surgery. Other modes of postoperative pain relief should be tried in these patients.

A new technique for long time catheterization of sacral epidural canal in rabbits.

PubMed

Erkin, Yüksel; Aydın, Zeynep; Taşdöğen, Aydın; Karcı, Ayşe

2013-01-01

In this study we aimed to develop a simple and practical technique for chronic sacral epidural catheterization of rabbits. We included ten rabbits weighing 2-2.5 kg in the study. After anesthesia and analgesia, we placed an epidural catheter by a 2 cm longitudinal skin incision in the tail above the sacral hiatus region. We confirmed localization by giving 1% lidocaine (leveling sensory loss and motor function loss of the lower extremity). The catheter was carried forward through a subcutaneous tunnel and fixed at the neck. Chronic caudal epidural catheter placement was succesful in all rabbits. The catheters stayed in place effectively for ten days. We encountered no catheter complications during this period. The localization of the catheter was reconfirmed by 1% lidocaine on the last day. After animals killing, we performed a laminectomy and verified localization of the catheter in the epidural space. Various methods for catheterization of the epidural space in animal models exist in the literature. Epidural catheterization of rabbits can be accomplished by atlanto-occipital, lumbar or caudal routes by amputation of the tail. Intrathecal and epidural catheterization techniques defined in the literature necessitate surgical skill and knowledge of surgical procedures like laminectomy and tail amputation. Our technique does not require substantial surgical skill, anatomical integrity is preserved and malposition of the catheter is not encountered. In conclusion, we suggest that our simple and easily applicable new epidural catheterization technique can be used as a model in experimental animal studies.

Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant.

PubMed

Angelini, Pierluigi; Sciuto, Antonio; Cuccurullo, Diego; Pirozzi, Felice; Reggio, Stefano; Corcione, Francesco

2017-07-01

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication. From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction. Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect. In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

Hydronephrosis Presenting 6 Months After Sacral Colpopexy: Case Report and Literature Review.

PubMed

Weber LeBrun, Emily; Santamaria, Estefania; Moy, Louis

The aim of this study was to describe a case of uterovaginal prolapse managed with robotic-assisted sacral colpopexy complicated by severe right-sided hydronephrosis despite normal intraoperative cystoscopy. A 68-year-old woman presented with a worsening vaginal bulge over the past 2 years. Tricompartment stage 2 uterovaginal prolapse, with dominant cystocele and skin erosion at the posterior fourchette from prolapse friction, was identified on physical examination, and the patient underwent pelvic reconstructive surgery, including sacral colpopexy. The patient was discharged on postoperative day 4 after being treated for a urinary tract infection. At her 6-week postoperative visit, the patient demonstrated normal vaginal support. She presented 6 months postoperatively with right-sided hydronephrosis with an almost imperceptible stricture where the right iliac vessels cross the pelvic brim, demonstrating a delayed manifestation of ureteral injury. She underwent open ureteroscopy, ureteroneocystostomy with vesicopsoas hitch, and ureteral stent placement. Ureteroscopy demonstrated a very mild narrowed caliber of the ureter just above the sacroiliac joint without overt obstruction. Follow-up intravenous pyelogram demonstrated no evidence of damage or obstruction. At nearly 1-year follow-up, the patient remained asymptomatic and had normal renal function. This case demonstrates the challenges of an uncommon, but highly morbid, complication of pelvic reconstructive surgery. Even when adequate visualization of the ureters and delicate ureteral dissection is achieved throughout surgery, occult injuries can still occur. Surgeons should maintain a high index of suspicion of ureteral injury when evaluating patients for late presentations of postoperative complications.

Frequency of an accessory popliteal efferent lymphatic pathway in dogs.

PubMed

Mayer, Monique N; Sweet, Katherine A; Patsikas, Michael N; Sukut, Sally L; Waldner, Cheryl L

2018-05-01

Staging and therapeutic planning for dogs with malignant disease in the popliteal lymph node are based on the expected patterns of lymphatic drainage from the lymph node. The medial iliac lymph nodes are known to receive efferent lymph from the popliteal lymph node; however, an accessory popliteal efferent pathway with direct connection to the sacral lymph nodes has also been less frequently reported. The primary objective of this prospective, anatomic study was to describe the frequency of various patterns of lymphatic drainage of the popliteal lymph node. With informed client consent, 50 adult dogs with no known disease of the lymphatic system underwent computed tomographic lymphography after ultrasound-guided, percutaneous injection of 350 mg/ml iohexol into a popliteal lymph node. In all 50 dogs, the popliteal lymph node drained directly to the ipsilateral medial iliac lymph node through multiple lymphatic vessels that coursed along the medial thigh. In 26% (13/50) of dogs, efferent vessels also drained from the popliteal lymph node directly to the internal iliac and/or sacral lymph nodes, coursing laterally through the gluteal region and passing over the dorsal aspect of the pelvis. Lymphatic connections between the right and left medial iliac and right and left internal iliac lymph nodes were found. Based on our findings, the internal iliac and sacral lymph nodes should be considered when staging or planning therapy for dogs with malignant disease in the popliteal lymph node. © 2018 American College of Veterinary Radiology.

Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial.

PubMed

Forni, Cristiana; D'Alessandro, Fabio; Gallerani, Pina; Genco, Rossana; Bolzon, Andrea; Bombino, Caterina; Mini, Sandra; Rocchegiani, Laura; Notarnicola, Teresa; Vitulli, Arianna; Amodeo, Alfredo; Celli, Guglielmo; Taddia, Patrizia

2018-06-01

Hip fractures in the elderly are a serious problem for the health service due to the high rate of complications. One of these complications is pressure ulcers that, according to the literature, occur in 8.8% to 55% of patients and mainly arise in the sacral area. The present randomised controlled trial tests whether applying a new innovative multi-layer polyurethane foam dressing (ALLEVYN LIFE™), reduces the onset of pressure ulcers in the sacral area. From March to December 2016, 359 fragility hip fracture patients were randomly divided into 2 groups: 182 in the control group and 177 in the experimental group. Pressure ulcers occurred overall in 36 patients (10%): 8 patients (4.5%) in the experimental group compared to 28 (15.4%) in the control group: P = 0.001, relative risk 0.29 (95% CI 0.14-0.61) with NNT of 9 (95% CI 6-21). In the experimental group the onset of pressure ulcers occurred on average on the 6th day compared to the 4th day in the control group (HR 4.4). Using polyurethane foam is effective at reducing the rate of pressure ulcers in the sacrum in elderly patients with hip fracture. The adhesiveness of this device also enables costs to be kept down. © 2018 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Familial Currarino syndrome associated with Hirschsprung disease: two cases of a mother and daughter.

PubMed

Ohno, Koichi; Nakamura, Tetsuro; Azuma, Takashi; Nakaoka, Tatsuo; Takama, Yuichi; Hayashi, Hiroaki; Horiike, Masaki; Zenitani, Masahiro; Higashio, Atsushi

2013-01-01

Currarino syndrome with Hirschsprung disease (CS-HD) is extremely rare. We present the first family with CS-HD. Case 1: A 28-year-old woman was admitted with severe abdominal distension and dyspnea. She was diagnosed with anal stenosis, hemisacrum, anterior sacral meningocele (ASM), tethered cord (TC), and short-segment aganglionosis. She underwent the modified Duhamel operation after meningocele repair and cord detethering. A bicornuate uterus, bilateral ovarian dermoid cysts, and small rectal duplication were also noted intraoperatively. Case 2: The daughter of case 1 was admitted for abdominal distension and anal stenosis at the age of 17 days. Studies revealed a hemisacrum, ASM, TC, presacral mass, atrial septal defect, polyp in the right nasal cavity, right vesicoureteral reflux, and short-segment aganglionosis. She underwent the modified Soave operation at the age of 1 year and 4 months after meningocele repair, cord detethering, and resection of the presacral mass (epidermoid cyst). In both cases, the aganglionic segments were confirmed by preoperative rectal suction biopsy and postoperative pathological examination on full-thickness rectal specimens. Some causal genes for Currarino syndrome (CS) and Hirschsprung disease (HD) are currently investigated. Thus far, 10 CS-HD cases have been reported, including 6 cases of familial CS. However, all the patients had sporadic HD. Recent reports suggest that anomalies of the enteric nerve system contribute to postoperative constipation in CS cases. Copyright © 2013 Elsevier Inc. All rights reserved.

Ultrasound-guided intrasphincteric botulinum toxin injection relieves obstructive defecation due to Hirschsprung's disease and internal anal sphincter achalasia.

PubMed

Church, Joseph T; Gadepalli, Samir K; Talishinsky, Toghrul; Teitelbaum, Daniel H; Jarboe, Marcus D

2017-01-01

Chronic obstructive defecation can occur in patients with Hirschsprung Disease (HD) and internal anal sphincter (IAS) achalasia. Injection of Botulinum Toxin (BoTox) into the IAS can temporarily relieve obstructive defecation, but can be challenging when performed by tactile sense alone. We compared results of BoTox injections with and without ultrasound (US) guidance. We retrospectively reviewed BoTox injections into the IAS for obstructive defecation over 5years. Analyzed outcomes included short-term improvement, defined as resolution of enterocolitis, new ability to spontaneously defecate, and/or normalization of bowel movement frequency 2weeks post-operatively, as well as requirement of more definitive surgical therapy (myotomy/myomectomy, colectomy, colostomy, cecostomy/appendicostomy, and/or sacral nerve stimulator implantation). Outcomes were compared using t-test and Fisher's Exact test, with significance defined as p<0.05. Twelve patients who underwent BoTox injection were included, including 5 patients who underwent injections both with and without ultrasound. Ten underwent an ultrasound-guided injection (13 injection procedures), 5 of whom had HD. Seven underwent an injection without ultrasound guidance (17 injection procedures), 5 of whom had HD. Procedures performed with US resulted in greater short-term improvement (76% versus 65% without ultrasound) and less requirement of a definitive procedure for obstructive defecation (p<0.05). US-guided BoTox injection is safe and effective for obstructive defecation, and may decrease the need for a definitive operation. III. Copyright © 2017 Elsevier Inc. All rights reserved.

[An update on ejaculation physiology and premature ejaculation definition, prevalence data, and etiology].

PubMed

Mas, M

2014-07-01

Ejaculation consists of two synchronized phases: a) emission, the contraction of the vas deferens, prostate and seminal vesicles and bladder neck expelling the seminal fluid to the urethra; it is mediated by sympathetic nerves, and b) expulsion, seminal fluid outward propulsion by the rhythmic contraction of perineal muscles. Ejaculation results from a complex spinal reflex having its essential components within the lumbosacral cord. The main afferent signals derive from mechanical stimulation of the glans penis and are conveyed by sacral sensory roots. The ejaculatory reflex is under strong modulatory influence from the brain through both facilitatory and inhibitory descending signals. Several central neurotransmitters including serotonin and dopamine modulate the ejaculatory reflex. The intravaginal ejaculatory latency time (IELT), measured or estimated, provides clinically useful assessment of the ejaculatory reflex. The new DSM-5 definition of premature ejaculation (PE) includes a specified time to ejaculation criterion (IELT of about one minute or shorter). Four subtypes of PE, showing different prevalence rates, have been proposed. PE etiology is multifactorial with interacting psychological and biological factors contributing to the disorder. A number of genetic polymorphisms related to serotonin and dopamine neurotransmission may predispose the bearers to developing PE. High prevalence rates of PE have been found in patients with chronic prostatitis, hyperthyroidism, and premature ejaculation. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Medicina Rural y Generalista (SEMERGEN). All rights reserved.

Recurrent genital herpes treatments and their impact on quality of life.

PubMed

Brentjens, Mathijs H; Yeung-Yue, Kimberly A; Lee, Patricia C; Tyring, Stephen K

2003-01-01

Herpes genitalis is one of the most common viral sexually transmitted diseases in the world, with an estimated seroprevalence in the US of greater than 20%. Two viruses of the same family cause herpes genitalis: herpes simplex virus 1 and 2. After the resolution of primary infection, the virus persists in the nerve roots of the sacral plexus, often causing recurrent (though generally less severe) outbreaks. These outbreaks, as well as the infectious potential to the patient's sexual partners, results in significant psychological stress on the patient, and has a tremendous negative impact on QOL. Current treatment modalities may result in a reduction in the number of outbreaks and viral shedding, but no cure exists. Although studies have clearly demonstrated the negative impact of recurrent genital herpes on QOL, an assessment scale specific to herpes was not developed until recently. Earlier studies indicated that patients did not perceive a significant benefit from episodic treatment with antivirals, but studies using the Recurrent Genital Herpes Quality of Life Questionnaire (RGHQoL) have now demonstrated that suppressive antiviral therapy improves quality of life in patients with frequent recurrences of genital herpes. However, not all patients with recurrent genital herpes need suppressive therapy, and proposed factors to consider include frequency of recurrence, physical and psychological distress caused by recurrences, and the potential for transmission to the patient's sexual partner. Newer therapeutic modalities, including the topical immune response modifier resiquimod and herpes vaccines, may eventually be shown to further decrease the psychological morbidity of recurrent genital herpes.

Elsberg syndrome

PubMed Central

Savoldi, Filippo; Kaufmann, Timothy J.; Flanagan, Eoin P.; Toledano, Michel

2017-01-01

Objective: Elsberg syndrome (ES) is an established but often unrecognized cause of acute lumbosacral radiculitis with myelitis related to recent herpes virus infection. We defined ES, determined its frequency in patients with cauda equina syndrome (CES) with myelitis, and evaluated its clinical, radiologic, and microbiologic features and outcomes. Methods: We searched the Mayo Clinic medical records for ES and subsequently for combinations of index terms to identify patients with suspected CES and myelitis. Results: Our search yielded 30 patients, 2 diagnosed with ES and an additional 28 with clinical or radiologic evidence of CES retrospectively suspected of having ES. We classified patients in 5 groups according to diagnostic certainty. MRI and EMG confirmed that 2 had only myelitis, 5 only radiculitis, and 16 both. Two had preceding sacral herpes infection and 1 oral herpes simplex. Spinal cord lesions were commonly multiple, discontinuous, not expansile, and centrally or ventrally positioned. Lesions generally spared the distal conus. Nerve root enhancement was occasionally prominent and was smooth rather than nodular. Lymphocytic CSF pleocytosis was common. Thirteen patients (43%) had viral isolation studies, which were commonly delayed; the delay may have accounted for the low rate of viral detection. Acyclovir was administered to 6 patients. Most patients recovered with sequelae; 1 patient experienced encephalomyelitis and died. Conclusion: ES is a definable condition likely responsible for 10% of patients with combined CES and myelitis. Radiologic findings are not entirely specific but may help in differentiating ES from some competing diagnostic considerations. We propose criteria to facilitate diagnosis. PMID:28534040

Elsberg syndrome: A rarely recognized cause of cauda equina syndrome and lower thoracic myelitis.

PubMed

Savoldi, Filippo; Kaufmann, Timothy J; Flanagan, Eoin P; Toledano, Michel; Weinshenker, Brian G

2017-07-01

Elsberg syndrome (ES) is an established but often unrecognized cause of acute lumbosacral radiculitis with myelitis related to recent herpes virus infection. We defined ES, determined its frequency in patients with cauda equina syndrome (CES) with myelitis, and evaluated its clinical, radiologic, and microbiologic features and outcomes. We searched the Mayo Clinic medical records for ES and subsequently for combinations of index terms to identify patients with suspected CES and myelitis. Our search yielded 30 patients, 2 diagnosed with ES and an additional 28 with clinical or radiologic evidence of CES retrospectively suspected of having ES. We classified patients in 5 groups according to diagnostic certainty. MRI and EMG confirmed that 2 had only myelitis, 5 only radiculitis, and 16 both. Two had preceding sacral herpes infection and 1 oral herpes simplex. Spinal cord lesions were commonly multiple, discontinuous, not expansile, and centrally or ventrally positioned. Lesions generally spared the distal conus. Nerve root enhancement was occasionally prominent and was smooth rather than nodular. Lymphocytic CSF pleocytosis was common. Thirteen patients (43%) had viral isolation studies, which were commonly delayed; the delay may have accounted for the low rate of viral detection. Acyclovir was administered to 6 patients. Most patients recovered with sequelae; 1 patient experienced encephalomyelitis and died. ES is a definable condition likely responsible for 10% of patients with combined CES and myelitis. Radiologic findings are not entirely specific but may help in differentiating ES from some competing diagnostic considerations. We propose criteria to facilitate diagnosis.

Computational Models of the Eye and their Applications in Long Duration Space Flight

NASA Technical Reports Server (NTRS)

Chen, Richard; Best, Lauren; Mason, Kyle; Mulugeta, Lealem

2011-01-01

Astronauts are exposed to cephalad fluid shift, increased carbon dioxide levels and other environmental factors during space flight. As a result of these conditions, it is believed that they are at risk of developing increased intracranial pressure (ICP) and intraocular pressure (IOP), which in turn may cause papilledema and other disorders of the eye that can lead to temporary or permanent changes in vision. However, the mechanisms behind this risk are not fully understood. Ground analog and flight studies pose challenges because there are limited non-invasive methods that can be used to study the eye and intracranial space. Therefore it is proposed that computational models can be applied to help address this gap by providing a low cost method for studying the effects of IOP, ICP and various properties of the eye on these diseases. The information presented by the authors provides a summary of several models found in literature that could potentially be augmented and applied to inform research. Specifically, finite element models of the optic nerve head, sclera and other structures of the eye can be readily adapted as potential building blocks. These models may also be integrated with a brain/cerebrospinal fluid (CSF) model which will take into account the interaction between the CSF fluid and its pressure on the optic nerve. This integration can enable the study of the effects of microgravity on the interaction between the vasculature system and CSF system and can determine the effects of these changes on the optic nerve, and in turn the eye. Ultimately, it can help pinpoint the influences of long-term exposure to microgravity on vision and inform the future research into countermeasure development. In addition to spaceflight, these models can provide deeper understanding of the mechanisms of glaucoma, papilledema and other eye disorders observed in terrestrial conditions.

Surgical fasciectomy of the trapezius muscle combined with neurolysis of the Spinal accessory nerve; results and long-term follow-up in 30 consecutive cases of refractory chronic whiplash syndrome

PubMed Central

2010-01-01

Background Chronic problems from whiplash trauma generally include headache, pain and neck stiffness that may prove refractory to conservative treatment modalities. As has previously been reported, such afflicted patients may experience significant temporary relief with injections of local anesthetic to painful trigger points in muscles of the shoulder and neck, or lasting symptomatic improvement through surgical excision of myofascial trigger points. In a subset of patients who present with chronic whiplash syndrome, the clinical findings suggest an affliction of the spinal accessory nerve (CN XI, SAN) by entrapment under the fascia of the trapezius muscle. The present study was undertaken to assess the effectiveness of SAN neurolysis in chronic whiplash syndrome. Methods A standardized questionnaire and a linear visual-analogue scale graded 0-10 was used to assess disability related to five symptoms (pain, headache, insomnia, weakness, and stiffness) before, and one year after surgery in a series of thirty consecutive patients. Results The preoperative duration of symptoms ranged from seven months to 13 years. The following changes in disability scores were documented one year after surgery: Overall pain decreased from 9.5 +/- 0.9 to 3.2 +/- 2.6 (p < 0.001); headaches from 8.2 +/- 2.9 to 2.3 +/- 2.8 (p < 0.001); insomnia from 7.5 +/- 2.4 to 3.8 +/- 2.8 (p < 0.001); weakness from 7.6 +/- 2.6 to 3.6 +/- 2.8 (p < 0.001); and stiffness from 7.0 +/- 3.2 to 2.6 +/- 2.7 (p < 0.001). Conclusions Entrapment of the spinal accessory nerve and/or chronic compartment syndrome of the trapezius muscle may cause chronic debilitating pain after whiplash trauma, without radiological or electrodiagnostic evidence of injury. In such cases, surgical treatment may provide lasting relief. PMID:20374624

Testing the assumption of normality in body sway area calculations during unipedal stance tests with an inertial sensor.

PubMed

Kyoung Jae Kim; Lucarevic, Jennifer; Bennett, Christopher; Gaunaurd, Ignacio; Gailey, Robert; Agrawal, Vibhor

2016-08-01

The quantification of postural sway during the unipedal stance test is one of the essentials of posturography. A shift of center of pressure (CoP) is an indirect measure of postural sway and also a measure of a person's ability to maintain balance. A widely used method in laboratory settings to calculate the sway of body center of mass (CoM) is through an ellipse that encloses 95% of CoP trajectory. The 95% ellipse can be computed under the assumption that the spatial distribution of the CoP points recorded from force platforms is normal. However, to date, this assumption of normality has not been demonstrated for sway measurements recorded from a sacral inertial measurement unit (IMU). This work provides evidence for non-normality of sway trajectories calculated at a sacral IMU with injured subjects as well as healthy subjects.

Managing the urinary tract in spinal cord injury

PubMed Central

Harrison, Simon C. W.

2010-01-01

This review sets out to provide an overview of the author’s approach to the management of the urinary tract in the patient who has suffered from an injury to their spinal cord. Emphasis is given to the need to understand the fundamental pathophysiological patterns that are seen with injuries that involve the sacral segments of the cord (the conus) and those that spare the conus but interrupt communication between the sacral parasympathetic and somatic centers and the brain (supraconal lesions). The importance of patient participation in management decisions is highlighted by considering the different ways in which the urinary tract can be managed and how the clinician needs to try to meet patient expectations and requirements while establishing safe urological management. Finally, consideration is given to the importance of establishing an appropriate follow up regime and managing urinary tract complications effectively. PMID:20877604