Fourth Sacral Nerves Research Articles

Pudendal Nerve Identified on Sectioned Images of Female Cadaveric Pelvis

To provide an anatomical atlas made of serially sectioned images of a female cadaver that clearly demonstrated the pudendal nerve. The courses of the pudendal nerve, internal pudendal artery, and internal pudendal vein were observed on the sectioned images of a female cadaver. The spatial relationship between the nerve and blood vessels was interpreted. Traces of the structures on the sectioned images showed that the sources of the sciatic and pudendal nerves were the fourth lumbar nerve to the second sacral nerve and the second to the fourth sacral nerves, respectively. As the borderline, the second sacral nerve showed a remarkable variation. The pudendal nerve gave off the internal rectal nerve proximal to the pudendal canal and it gave off the muscular branch to the urogenital triangle in the pudendal canal. It was divided into the posterior labial nerve and the dorsal nerve of clitoris distal to the pudendal canal. Inside the pudendal canal, the internal pudendal vein, internal pudendal artery, and pudendal nerve were arranged from superomedial to inferolateral order. In other words, the pudendal nerve was the farthest from the uterus. The sorted sectioned images with labels, accompanied by the schematic drawings, could serve as references for interpreting clinical images and conducting procedures related to pudendal nerve conditions.

Electrical stimulation in the treatment of bladder dysfunction: technology update.

The urinary bladder has two functions: urine storage and voiding. Clinically, two major categories of lower urinary tract symptoms can be defined: storage symptoms such as incontinence and urgency, and voiding symptoms such as feeling of incomplete bladder emptying and slow urinary stream. Urgency to void with or without incontinence is called overactive bladder (OAB). Slow urinary stream, hesitancy, and straining to void with the feeling of incomplete bladder emptying are often called underactive bladder (UAB). The underlying causes of OAB or UAB can be either non-neurogenic (also referred to as idiopathic) and neurogenic, for example due to spinal cord injury or multiple sclerosis. OAB and UAB can be treated conservatively by lifestyle intervention or medication. In the case that conservative treatment does not provide sufficient benefit, electrical stimulation can be used. Sacral neurostimulation or neuromodulation (SNM) is offered as a third-line therapy to patients with non-neurogenic OAB or UAB. In SNM, the third or fourth sacral nerve root is stimulated and after a test period, a neuromodulator is implanted in the buttock. Until recently only a non-rechargeable neuromodulator was approved for clinical use. However, nowadays, a rechargeable sacral neuromodulator is also on the market, with similar safety and effectiveness to the non-rechargeable SNM system. The rechargeable device was approved for full body 1.5T and 3T MRI in Europe in February 2019. Regarding neurogenic lower urinary tract dysfunction, electrical stimulation only seems to benefit a selected group of patients.

Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia

Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. Observational study. University hospital. One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach.

Identification of sacral plexus at robot-assisted nerve-sparing radical hysterectomy with extended lymphadenectomy

목적: Demonstrate a new instrument, technique or procedure 방법: We use da Vinci system to demonstrate surgical technique of identification of Sacral plexus in part of Robot assisted nerve sparing radical hysterectomy with extended lymphadenectomy for early cervical cancer. It necessary to understand anatomy of deep sacral plexus to prevent the nerve injury in case of extensive lymphadenectomy in high risk cervical cancer. The sacral plexus is formed by the union of the lumbosacral trunk (from the anterior rami of L4 and L5) and the anterior rami of the first, second, third, and fourth sacral nerves. The nerves forming the sacral plexus converge to the lower part of the greater sciatic foramen and unite to form a flattened band, sciatic nerve. The clinical significant of sacral plexus is that an injury to the sacral plexus, leaves the patient with a deficit in the sensation and/or movement and experience neuropathic pain in the lower limb supplied by the corresponding nerve(s) affected. After extended lymphadenectomy, we could confirm the pelvic anatomy more clearly including superior hypogastric plexus, promontory, lower part of aorta, common iliac vessels, hypogastric nerve communicating with parasympathetic nerves, and vesical branches of inferior hypogastic plexus. And sacral plexus, lumbosacral trunk, S1, S2 and S3. 결과: No intraoperative complications or postoperative nerve injury that required treatment occurred. 결론: It would be expected in sacral plexus identifying extended lymphadenectomy that the more number of lymph nodes, metastatic nodes and therapeutic benefits for improvement of survival. However, it needs to evaluate long term survival benefit and functional benefits about identifying sacral plexus extended lymphadenectomy

Sacral nerve stimulation is a valuable diagnostic tool in the management of anorectal and pelvic malformations

BackgroundWe hypothesize that the current practice of sphincter assessment in anorectal malformations (ARMs) by direct muscle stimulation can be improved by sacral nerve stimulation (SNS). Focusing on the specific adjustments for infants, we highlight the anatomical and neurophysiologic basis of SNS and its further diagnostic and therapeutic implications. Patients and MethodsWe examined 20 patients: 12 patients with ARM, 3 with Hirschsprung disease, 3 with sacrococcygeal teratoma, and 2 with cloacal exstrophies. Under general anesthesia and ultrasound guidance, percutaneous needle electrodes were placed within the sacral neural foramina. Electrical stimulation was applied to assess the presence, pattern, and extent of the neuromuscular response of the external anal sphincter. ResultsWe successfully modified the traditional method used in adults replacing radiographic controls by ultrasound guidance. In 20 SNS procedures with no complications, we found a muscle response on stimulation of the third and/or fourth sacral nerves in 18 of 20 patients (anal sphincter contraction and/or ipsilateral plantar flexion). ConclusionWe demonstrated the feasibility of SNS for intraoperative sphincter mapping and detection of primary innervation abnormalities in ARM as well as for the assessment of secondary deficits in postoperative follow-up. Sacral nerve stimulation broadens the spectrum of intraoperative information concerning the sacral innervation pattern by a direct assessment of the sacral nerves. Furthermore, electrophysiologic data may allow prospective criteria for sphincter function to be established. These may improve the accuracy of the present classification-based prognosis as well as the understanding of sphincter physiology in general.

Leprosy affects the tibial nerves diffusely from the middle of the thigh to the sole of the foot, including skip lesions.

This study investigated where leprosy affects the posterior tibial nerve and whether neurolysis is beneficial. Nine patients with bilateral posterior tibial leprous neuropathy with no sensorimotor recovery were studied. Preoperative sensory-muscle and nerve conduction velocity testing revealed the tarsal tunnel to be the site of a severe lesion in all cases. During surgery, the most proximal site of the nerve lesion was detected by electrically stimulating the spinal roots from the second lumbar nerve to the fourth sacral nerve, evoking efferent mixed nerve compound action potentials that were recorded from the exposed tibial nerve. In all patients, the nerve compound action potentials became normal only proximal to the sciatic nerve bifurcation. Epineuriotomy within these seemingly unaffected segments revealed fibrosis of the interfascicular epineurium. Interfascicular neurolysis was performed on all affected segments. A 2-year follow-up showed an increase in girth of the proximal calf musculature in six of eight patients (the ninth patient had no recordable nerve conduction velocity). It was concluded that (1) leprosy affects the tibial nerves in a scattered way from the sciatic nerve main trunk distally to the exit of the tarsal tunnel; and (2) interfascicular, microsurgical neurolysis is beneficial provided that it is performed on all affected nerve segments.

Localized Neurofibromatosis of the Female Genitourinary Tract

The internal female genital tract is rarely involved in neurofibromatosis. This report details a case of diffuse neurofibroma with prominent Wagner-Meissner body differentiation involving uterine cervix and endocervix, vagina, and vulva. The urinary bladder, urethra, and one ureter were also extensively affected. The anatomic localization of the lesions in this case is consistent with segmental neurofibromatosis restricted to the distribution of the second, third, and fourth sacral nerves. Failure to consider the possibility of genitourinary involvement in neurofibromatosis, the potential for localized manifestations in the absence of other easily recognized stigmata, and the subtle histologic features in small tissue biopsies may cause difficulty in diagnosis.

Influence of sacral nerves on the internal anal sphincter of the opossum.

The purpose of the present studies is to 1) compare the effects of stimulation of different sacral nerves (S1-S5) on internal anal sphincter (IAS) pressures and 2) examine the nature of synaptic transmission in the sacral inhibitory pathway to the IAS. Pressures from the IAS of alpha-chloralose-anesthetized opossums were recorded using a low-compliance continuously perfused catheter assembly. Electrical stimulation of the third and fourth sacral nerves (S3 and S4) caused frequency-dependent IAS relaxation, whereas stimulation of other sacral nerves was without significant effect on the IAS. Relaxation of the IAS in response to S4 stimulation was not significantly modified by atropine, pirenzepine dihydrochloride, hexamethonium chloride, or adrenergic antagonists. However, a combination of either atropine and hexamethonium or pirenzepine and hexamethonium caused a significant antagonism of sacral nerve-stimulated relaxation without modifying the inhibitory responses of local transmural nerve stimulation and isoproterenol. From these studies we conclude that 1) in the opossum the sacral nerves primarily exert inhibitory influences on the IAS and 2) the sacral inhibitory pathway involves the release of acetylcholine from preganglionic fibers, which in turn causes the activation of both muscarinic (M1) and nicotinic receptors on postganglionic, noncholinergic, nonadrenergic inhibitory neurons.

Experience and recent contributions in sacral nerve stimulation for voiding in both human and animal.

SUMMARYPreliminary investigations on sixty‐four dogs and five human paraplegics in the past three years have led to the location of neural trigger points, which in the human were found to be the third and fourth sacral nerves at their exit from the sacral foramina anteriorly. Successful voiding was induced with reproducible results for four to five months using an electrical current about 80 to 100 times smaller than the one used for stimulation of the muscle directly.An interesting by‐product of this chronic stimulation led to the discovery of a neural trigger point which, when stimulated, causes immediate and sustained erection of the penis in paraplegic patients. We plan to try our methods in cases of impotence caused by a nerve lesion proximal to the point of electrical nerve excitation.The present work consists mainly in improving our surgical approach in the human and designing electrodes of special configuration with material well insulated. The electronic exciting mechanism is also being developed in miniature size for prolonged use. Special precautions are being developed to minimise as much as possible the inflammatory reaction of nerve tissue to the electrodes.

Sexual dysfunction following radical surgery for cancer of the rectum

Sexual impotence is a common complication after abdominoperineal excision of cancer of the rectum, varying from 53 to 100 per cent in the recent experience of ten prominent surgeons. This contrasts sharply with the incidence of less than 10 per cent of impotence after rectal excision for ulcerative colitis. Ejaculation is controlled by the lumbar sympathetic system, probably the first lumbar ganglia. Control of erection is a function of the pelvic parasympathetic nerves originating from the second, third and fourth sacral nerves, the presacral plexus, and the pelvic parasympathetic multiple nerve fibers that travel around the lateral perirectal tissues and go to the area of the prostate gland. Probably these nerves are divided in the course of radical lateral dissections associated with operations for malignancy, and are a necessary price that has to be paid for thorough pelvic lymphatic dissection.

Regarding the length and extent of the human medulla spinalis

The Anatomical RecordVolume 10, Issue 9 p. 559-564 Article Regarding the length and extent of the human medulla spinalis Rollo E. McCotter, Rollo E. McCotter Department of Anatomy, University of MichiganSearch for more papers by this author Rollo E. McCotter, Rollo E. McCotter Department of Anatomy, University of MichiganSearch for more papers by this author First published: July 1916 https://doi.org/10.1002/ar.1090100902Citations: 40AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume10, Issue9July 1916Pages 559-564 RelatedInformation