S1 Root Research Articles

Excision of Deep Endometriosis Nodules of the Sciatic Nerve in 10 Steps

To present 10 standardized and reproducible surgical steps allowing for complete excision of deep endometriosis nodules involving the sciatic nerve. Surgical education video. The local institutional review board confirmed that the video met the ethical criteria required for publication. Patient consent was obtained. Tertiary referral center. The excision of deep endometriosis involving the sciatic nerve may be performed following 10 steps: (1) Longitudinal incision of the peritoneum covering the external iliac artery, from the hypogastric vessels to the round ligament and the identification of the genitofemoral nerve. (2) Dissection of the iliolumbar space identified laterally by the psoas muscle and medially by the external iliac artery and vein [1-5]. (3) Identification of the obturator nerve. The dissection is performed on contact with the psoas muscle; when the nerve is surrounded by the nodule, its releasing is progressively carried out. (4) Identification of the obturator vessels, which cross the obturator nerve beneath and follow a lateral direction. (5) Opening of the lumbosacral space, below the level of the obturator nerve, and the identification of the sciatic nerve, resulting from the confluence of L4 to S3 roots. During this step, the deep endometriosis nodule is identified on contact with the greater sciatic foramen. (6) Opening of the broad ligament, between the external iliac vessels and the umbilical artery, and identification of the obturator nerve, as it is usually performed in pelvic lymphadenectomy. The surgeon may either perform a separate incision of the posterior leaf of the broad ligament and medial to the infundibulo-pelvic ligament or prolong medially the incision made at step 1. (7) Identification of the sciatic nerve, which is seen below and medially from the obturator nerve and obturator vessels. During this step, the posterior limit of the nodule is identified. (8) Identification of sacral roots S1, S2, and S3 [6]. The pudendal nerve and the posterior femoral cutaneous nerve may be identified below the S3 and medially from the sciatic nerve and before their exit through the greater sciatic foramen. The posterior and medial limit of the nodule is progressively released [7]. (9) The dissection is continued laterally, on contact with the ischium, down to the ischial spine and the coccygeus muscle. The lateral limit of the nodule is identified and released. (10) The anterior limit of the nodule is identified and, when required, is separated from the bladder. The latter 3 steps are less standardized, and the surgeon may alternate lateral, medial, posterior, and anterior dissection of the nodule, depending on the intraoperative circumstances. In most cases, the nerves are compressed but not infiltrated inside the epineurium, and their complete releasing is followed by significant or complete relief of pain and motor problems [6]. When the nodule infiltrates the nerves inside the epineurium, the excision may be performed into the nerve. Laparoscopic excision of deep endometriosis nodules involving the sciatic nerve is a challenging procedure, requiring good anatomic knowledge, surgical skills, preliminary specific training, and multidisciplinary postoperative care. Teaching such a complex procedure is a mandatory but delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the external iliac, obturator, and pudendal vessels; preserve somatic nerves; and successfully excise deep endometriosis nodules. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and should be adapted to the patient.

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum-The Rouen Technique.

The complete excision of low rectovaginal deep endometriosis is a demanding surgery associated with an increased risk of intra- and postoperative complications, which can impact the quality of life. Given the choices of optimal surgery procedures available, we would like to emphasize that a minimally invasive approach with plasma medicine and a transanal disc excision could significantly improve surgery for deep endometriosis, avoiding the lateral thermal damage of vascular and parasympathetic fibers of roots S2–S5 in the pelvic plexus. The management of low rectal deep endometriosis is distinct from other gastrointestinal-tract endometriosis nodules. Suggestions and explanations are presented for this minimal approach. These contribute to individualized medical care for deep endometriosis. In brief, a laparoscopic transanal disc excision (LTADE; Rouen technique) was performed through a laparoscopic deep rectal dissection, combined with plasma energy shaving, and followed by a transanal disc excision of the low and mid-rectal deep endometriotic nodules, with the use of a semi-circular stapler. LTADE is indicated as the first-line surgical treatment for low and mid-rectal deep endometriotic nodule excisions, because it can preserve rectal length and innervation. This technique requires a multidisciplinary team with surgical colorectal training.

Deep infiltrating endometriosis with sacral plexus involvement: Improving knowledge through human cadaver dissection

IntroductionThe aim of this study was to assess a human cadaver model of sacral plexus dissection for learning about deep innervation in the female pelvis, and the latter's relationship with deep infiltrating endometriosis. MethodsThis was a prospective, observational study. Eight residents in obstetrics and gynecology were tested before and after a lecture on innervation of the female pelvis and a cadaver dissection class. Standardized cadaver dissection was used to identify the sacral nerve roots S2 to S4, superior and inferior hypogastric plexuses, hypogastric nerve, and splanchnic nerves. ResultsThe residents’ level of knowledge improved significantly after a one-hour lecture (p = 0.9.10−5) and after a cadaver dissection class (p = 0.6.10−6). The improvement was significantly greater for the dissection class (p = 0.0003). All the pelvic nerve structures were identified in all but one of the cadavers and had similar measurements. A vascular anatomical variant was observed in one case. ConclusionA human cadaver model is of value for learning about deep pelvic innervation and the latter's relationship with deep infiltrating endometriosis. The reproducibility and safety of cadaver dissection might improve surgical skills.

Nerve transfer for restoration of lower motor neuron-lesioned bladder function. Part 2: correlation between histological changes and nerve evoked contractions.

We determined the effect of pelvic organ decentralization and reinnervation 1 yr later on urinary bladder histology and function. Nineteen canines underwent decentralization by bilateral transection of all coccygeal and sacral (S) spinal roots, dorsal roots of lumbar (L)7, and hypogastric nerves. After exclusions, eight were reinnervated 12 mo postdecentralization with obturator-to-pelvic and sciatic-to-pudendal nerve transfers, then euthanized 8-12 mo later. Four served as long-term decentralized only animals. Before euthanasia, pelvic or transferred nerves and L1–S3 spinal roots were stimulated and maximum detrusor pressure (MDP) recorded. Bladder specimens were collected for histological and ex vivo smooth muscle contractility studies. Both reinnervated and decentralized animals showed less or denuded urothelium, fewer intramural ganglia, and more inflammation and collagen, than controls, although percent muscle was maintained. In reinnervated animals, pgp9.5+ axon density was higher compared with decentralized animals. Ex vivo smooth muscle contractions in response to KCl correlated positively with submucosal inflammation, detrusor muscle thickness, and pgp9.5+ axon density. In vivo, reinnervated animals showed higher MDP after stimulation of L1–L6 roots compared with their transected L7–S3 roots, and reinnervated and decentralized animals showed lower MDP than controls after stimulation of nerves (due likely to fibrotic nerve encapsulation). MDP correlated negatively with detrusor collagen and inflammation, and positively with pgp9.5+ axon density and intramural ganglia numbers. These results demonstrate that bladder function can be improved by transfer of obturator nerves to pelvic nerves at 1 yr after decentralization, although the fibrosis and inflammation that developed were associated with decreased contractile function.

Resection of S1 root schwannoma with extravertebral retroperitoneal spread via posterior median and laparoscopic approach

The authors report simultaneous surgical treatment of the right S1 root schwannoma with extravertebral retroperitoneal spread. Well-equipped operating theatre, professional experience and multidisciplinary approach involving neurosurgeons and abdominal surgeons ensure total minimally invasive simultaneous resection of schwannoma via posterior median and laparoscopic approach.

Periosteal Variety of Sacral Osteoid Osteoma Encroaching into the Spinal Canal – Treatment with a Tubular Retractor System: Case Report

Background: Osteoid osteomas are benign primary bone tumors with a predilection for posterior elements of the spinal column. Complete surgical excision through a traditional open approach is the treatment of choice for patients not responding to non-steroidal anti-inflammatory medications and patients with contraindications for nidus ablation. The study aims to highlight an alternative minimally invasive technique for complete surgical excision of osteoid osteoma encroaching into the spinal canal. Methods: We report a case of 22 years-old obese male suffering from left S1 radiculopathy and night pain. Magnetic resonance imaging and computed tomography (CT)-scan of the lumbosacral region revealed a benign bony lesion of size 13 mm × 11 mm × 8 mm encroaching from S1 lamina into the spinal canal and compressing left S1 root. Peri-lesional bony sclerosis and soft tissue edema were absent. In view of obesity and a small size of the lesion, it was decided to remove the lesion with a tubular retractor system under general anesthesia. Complete resection of the lesion was carried out sparing the L5-S1 facet, with a minimally invasive approach. Results: Patient had complete symptomatic improvement after the surgery. Histopathology showed interconnected trabeculae of woven bone matrix rimmed by osteoclasts consistent with the diagnosis of osteoid osteoma. Post-operative CT scan showed that the nidus was removed completely and important structures such as facet, pedicle, and midline posterior ligament complex were preserved. The patient resumed his daily activities and remained symptoms-free at the end of 6 months of follow-up. Conclusion: Minimally invasive surgery using a tubular retractor system can be safe and effective alternative to traditional open surgery for excision of osteoid osteoma from the posterior elements. Faster recovery, minimal tissue damage, and early return to work are added advantages for an obese patient undergoing minimally invasive total surgical excision. Keywords: Benign bone tumors, Sacral spine, Osteoid osteoma, Periosteal osteoid osteoma, Minimally invasive spine surgery, Tubular retractor system

Technical challenges of performing S1 root block: role for double needle and multilevel needle technique.

S1 root block is performed for pain in the lower limbs due to S1 nerve root inflammation at the L5/S1 disc level or compression in the lateral recess. We often note anterior or posterior spread of contrast away from the L5/S1 disc through an anatomically appropriate needle tip placement. We frequently encounter vascular spread when performing S1 root blocks, and the reported incidence varies between 10.4% and 27.8%. There is no clear strategy published to manage these challenges. In such clinical scenarios, we propose a double needle and/or a multilevel needle technique. A 39-year-old male presented with radicular pain in the left S1 distribution which matched the magnetic resonance imaging (MRI) scan findings and thus he was listed for a left S1 root block. A 22G needle was placed at the S1 level and upon injecting the contrast, vascular spread and anterior and distal spread along the nerve root were noted and the contrast did not reach the site of the pathology, the L5/S1 disc. The contrast continued to spread anteriorly despite withdrawing the needle. A second needle was placed medial and inferior to the first needle and the contrast spread now was adequate, that is, towards the L5/S1 disc and thus the injection was accomplished in a safe and satisfactory manner without needing to reschedule the procedure. Double needle technique can assist in overcoming problems encountered when performing an S1 root block. The alternatives could be the multilevel technique or to reschedule the procedure or consider a less optimal technique such as a caudal or a lumbar interlaminar epidural. In this technical report, we have highlighted various intervention options to mitigate such challenges and included a flow diagram to assist in decision-making. We have also discussed the possibility of altering the consent to accommodate the changes to the planned procedure.

Symptomatic intraspinal lumbosacral pseudomeningocele, a late consequence of root avulsion injury secondary to a gunshot wound

BackgroundTraumatic pseudomeningocele are usually a late consequence of cervical root avulsion injury and its occurrence in lumbosacral region is rare. This pathology is mostly due to violent blunt traumatic events and usually develops outside of the spinal canal. Occasionally, a pseudomeningocele may grow inside of the spinal canal causing delayed neurological deficit due to compromise of the adjacent neural structures. Case descriptionEvaluation of a delayed left lower extremity weakness in a young man with a history of a gunshot wound injury revealed an extradural pseudomeningocele arising from an S1 root avulsion injury with compressive effect on the adjacent L5 root OutcomeExcision of the cyst wall and reinstitution of the nerve root sheath resulted in an uneventful recovery ConclusionTo the best of our knowledge, the presented case with traumatic pseudomeningocele is the first example secondary to high velocity bullet injury. Furthermore, management of traumatic intraspinal pseudomeningocele subsequent to root avulsion injury has not been paid sufficient attention. In this paper, the surgical strategy will be discussed in detail.

Pudendal mapping of S1 rootlets in a functional posterior rhizotomy: when an S1 posterior root shows a high pudendal dorsal action potential-a technical note.

The standard level for lesioning in a functional posterior rhizotomy (FPR) ranges from L2 to S1/S2. Lesioning of the S1 and S2 rootlets strongly correlates with a reduction in ankle spasticity. In the Japanese population, the S2 root often shows the highest dorsal root action potentials (DAPs) in the afferent fibers of the pudendal nerve and is not lesioned to preserve postoperative urinary function. Thus, cutting of the S1 root plays a key role in reducing ankle spasticity in FPR. However, on rare occasions, even an S1 root may show high DAP in the afferent fibers of the pudendal nerve. The present, brief, technical note aimed to describe how an S1 root with a relatively high DAP in the afferent fibers of the pudendal nerve may be handed. In the procedure, the S1 root is divided into several rootlets, and each rootlet is tested for the pudendal mapping. A train of electrical stimuli is delivered to each rootlet in the standard FPR. If electromyography (EMG) findings after electrical stimulation are highly abnormal while the pudendal mapping demonstrates no or a relatively low DAPs, the rootlet is cut. In contrast, even if the rootlet shows highly abnormal EMG findings, it is preserved if mapping demonstrates a relatively high DAP. The S1 pudendal mapping is combined with EMG findings to achieve satisfactory reduction in ankle spasticity while preserving urological function.

Growth and physiological responses of selected pakchoi varieties to Plasmodiophora brassicae infection

Clubroot disease, caused by Plasmodiophora brassicae, is a serious soil-borne disease of Brassica crops worldwide. Pakchoi is one of the most important cruciferous vegetable crops and commonly infected by P. brassicae. To date, the physiological changes and mechanism of pakchoi in response to P. brassicae are largely unknown. In this study, seedlings of two pakchoi cultivars, cv. Xinxiaqing (a clubroot-susceptible cultivar) and Yanlong (a less susceptible cultivar than Xinxiaqing), were inoculated with P. brassicae. Results showed that infected roots were enlarged and changed into club shape galls. Fresh root weight, relative electrical conductivity, the activity of lactate dehydrogenase (LDH) and alcohol dehydrogenase (ADH) in infected roots were significantly induced. In contrast, a significant reduction of root length, root function, and the activity of succinic dehydrogenase (SDH), catalase (CAT), ascorbate peroxidase (APX), and superoxide dismutase (SOD) were observed in diseased roots. Interestingly, activities of malate dehydrogenase (MDH) and peroxidase (POD) in S1 and S2 plant roots were increased and decreased in S3 plant roots. Additionally, infected Xinxiaqing roots showed more serious disease symptoms than Yanlong, and the antioxidant enzyme activities were lowered in Xinxiaqing roots compared with those in infected Yanlong roots, indicating the importance of these enzymes in plant resistance against clubroot disease.

Tibial motor and sural electrophysiological relationship in subjects without and patients with mild axonal peripheral neuropathy.

The distal motor fibers of the tibial and sural nerves are predominantly derived from the S1 root. We aimed to describe the electrophysiological relationship of these two nerves. Clinical, radiological and neurophysiological data of patients with mild, length-dependent, peripheral neuropathy (PN) and subjects without PN were retrospectively collected and analyzed. Eighty-eight individuals without PN and 24 patients with mild axonal PN who had no evidence of lumbosacral radiculopathy were included for analysis. Significant positive correlations were observed for the tibial CMAP and the sural SNAP for both controls and patients. Multivariate linear regression analyses showed that the predicted tibial CMAP can be calculated using the following equations: for male subjects without PN, tibial CMAP = 20.7 - 0.21 × age; for female subjects without PN, tibial CMAP =23.3 - 0.21 × age and for patients with mild PN, tibial CMAP = 2.7 + sural SNAP. This study demonstrates the high correlation between the tibial CMAP and the sural SNAP in subjects without PN and patients with mild axonal peripheral neuropathy, and provides mathematical equations for the calculation of the predicted tibial CMAP for such individuals.

How we do it: Identification and Dissection of the Sacrospinous Ligament and Lumbosacral Spinal Root on a Patient with Endometriosis of the Pelvic Floor

Video Objective Our aim is to raise awareness of pelvic floor endometriosis and describe a technique to dissect the pelvis until the pelvic floor muscles identifying the lumbosacral nerves and the main structures of the pelvis. Setting A 23-year-old woman with cyclic pelvic pain since menarche had a history of claudication and pain in the right lower limb accompanied by dyschezia. At the vaginal and rectal examination, the patient had a nodule in the region of the right sacrospinous ligament, fixed in the pelvis and painful to palpation. The MRI showed a right posterolateral vaginal wall lesion on the uterosacral ligament and the anterior wall of the rectum, that touched the levator ani muscle infiltrating the sacrospinous ligament. Interventions The medial dissection of the lesion was performed by developing the pararectal space, resecting the uterosacral ligaments, ureterolysis and identifying the hypogastric nerve. Then, during lateral dissection of the lesion, we identified the iliac vessels and the obturator nerve after pelvic lymphadenectomy. The lumbar trunk, the sacral root S1, the superior gluteal artery and the S2 and S3 roots were identified posteriorly. Thus, we identified the lesion extending from the paracolpus and the rectal wall to the sacrospinous ligament in contact with the levator ani muscle. With both sides dissected, it was possible to approach the lesion preserving noble structures such as the ureter, uterine artery and splanchnic nerves. Conclusion Although endometriosis on the pelvic floor is a rare condition, deeply infiltrating endometriosis is more often diagnosed in young woman such as our patient. Surgical techniques must be developed to asses those type of lesions and videos like this are a form to discuss different approaches to the pelvic floor.

Electrodiagnostic characteristics of upper lumbar stenosis: Discrepancy between neurological and structural levels

Conventional knowledge suggests that n/n + 1 level lesion will result in n + 1 radiculopathy in the lumbar spine. However, anecdotal reports on spinal stenosis at upper lumbar levels suggest a difference. This study aimed to investigate electrodiagnostic manifestation of upper lumbar stenosis. Consecutive patients were recruited from a university hospital. Inclusion criteria were spinal canal stenosis at L1/2, L2/3, or L3/4 level confirmed in magnetic resonance image (MRI), abnormal electromyography (EMG) including active denervation potentials, and MRI and EMG conducted within 3 months interval. Exclusion criteria were concomitant peripheral polyneuropathy of clinical significance, structural lesions at L4/5 or L5/S1 levels in MRI to explain EMG abnormalities. 24 patients were included and 10 patients were excluded; 14 patients were enrolled in the study. All the patients showed denervation potentials in the distal lower extremity muscles innervated by L5 and S1 roots although the structural lesions were above. L2, L3, or L4 myotomes were rarely affected; only one case exhibited chronic reinnervation in the vastus medialis. Active denervation in the proximal L5 or S1 innervated muscles were observed in 8 patients. Any neuropathic findings were observed bilaterally in 10 patients. All the EMG findings could be categorized into 4 types based on symmetry, length-dependency, and myotomal distributions: symmetric, length-dependent (5), bilateral, asymmetric, non-length-dependent (5), unilateral, non-length-dependent (2), and mono-radiculopathy (2). In conclusion, general belief on lumbar radiculopathy was not applicable to upper lumbar stenosis. Without the knowledge of electrodiagnostic characteristic of upper lumbar stenosis, it might be confused as a peripheral polyneuropathy or polyradiculitis.

Effect of Combined Traditional Acupuncture, Pharmacopuncture and Applied Kinesiology on Lumbar Diseases of Resident Patients.

ObjectivesRecently several Korean medical doctors have begun practicing applied kinesiology (AK). Although the efficacy of combining traditional acupuncture (TA) and pharmacopuncture (PP) on lumbar diseases such as lumbar spinal stenosis (LSS) and lumbar herniation of intervertebral disk (LHID) has been examined, the possible benefits of combining TA, PP and AK approaches have not been examined. Therefore the aim of this study was to develop effective treatment for lumbar disorders by combining TA, PP, and AK treatments.MethodsTwenty-four patients hospitalized at Samse Korean Traditional Medicine Hospital between March and September 2018 with L5 or S1 root radiculopathy associated with LSS and LHID were included in this study. They were treated for 10 days with TA, PP and AK approaches that included category block, manipulation and strain/counterstrain treatments. The primary outcomes were mainly assessed using Japanese Orthopedic Association lumbar scores (JOALS). JOALS were determined before the start of treatment as well as five and 10 days after treatment started.ResultsThe treatments improved the lumbar condition of the patients based on JOA pain score.ConclusionThe combined TA, PP and AK treatments were effective in treating spinal diseases of resident patients. Prospective, controlled, and relevant protocols using multimodal strategies to define the role of TA, PP and AK are needed.

Suppression of Urinary Voiding “on Demand” by High-Frequency Stimulation of the S1 Sacral Nerve Root in Anesthetized Rats

High-frequency (kHz) stimulation of preganglionic pelvic nerve afferents can inhibit voiding in both anesthetized and conscious rats. The afferents travel via the S1 sacral nerve root, which is easier to access than the distal pelvic nerve fibers within the abdominal cavity. We therefore investigated whether voiding could be inhibited by high-frequency stimulation at S1 and how this compared to distal pelvic nerve stimulation. Urethane-anesthetized rats were instrumented to record bladder pressure and abdominal wall electromyogram and to stimulate the distal preganglionic pelvic nerve bundle and S1 sacral root. Saline was infused continuously into the bladder to evoke repeated voiding. Stimulation was initiated within 1-2 sec of the onset of the steep rise in bladder pressure signaling an imminent void. In six rats, stimulation of the distal pelvic nerve bundle (1-3 kHz sinusoidal waveform 1 mA, 60 sec) supressed the occurrence of an imminent void. Voiding resumed within 70 ± 13.0 sec (mean ± SEM) of stopping stimulation. Stimulation (using the same parameters) of the S1 root at the level of the sacral foramen suppressed voiding for the entire stimulation period in three rats and deferred voiding for 35-56 sec (mean 44.0 ± 3.2 sec) in the remaining three. Stimulation at either site when the bladder was approximately half full, as estimated from previous intervoid intervals, had no effect on voiding. This preliminary study provides proof-of-concept for the sacral root as an accessible target for high-frequency stimulation that may be developed as an "on demand" neuromodulation paradigm to suppress unwanted urinary voids. The authors reported no conflict of interest.

P16-S Isolated lower-leg pain and A-wave studies: A case report

An isolated lower-leg pain without neurological manifestations is an important problem in clinical practice. A-wave has been found in many cases but its significance remains unclear. We described a case of a 29-year-old woman, a bank employee, complaining of the lower-leg pain in the calf muscle on the left side. It continued over a year causing discomfort, excruciating muscle pain, accompanied by episodes of shooting pains that would appear in the morning and on sitting at desk at work for a long time. The pains disappeared during a walk. Intensity of the pain was 3.0 points when assessed on the visual analogue scale and 4.0 points on the DN4 questionnaire. Neurological investigations revealed only a Lasegue sign (60°) on the left side. Lumbosacral spine MRI showed a diffuse dorsal protrusion of the intervertebral discs L4-L5 2.1 mm, L5-S1 2.3 mm. Nerve conduction studies demonstrated normal motor and sensory conduction velocities in peroneal, tibial and sural nerves. No changes were recorded in the H-reflex studies. F-wave studies at distal and proximal point stimulation of the left tibial nerve showed the presence of the A-wave immediately before the F-wave. After month of regular visits to the swimming pool and the vascular medicines treatment, the patient observed that lower-leg pain significantly decreased. Conclusion The isolated lower-leg pain has been regarded as a neuropathic one with its source in the S1 root on the left side. This observation indicates clinical importance of studying and analyzing of A-waves in the lower limbs pain.

Establishment of hairy root cultures of Rehmannia elata N.E. Brown ex Prain and production of iridoid and phenylethanoid glycosides

Hairy root lines were established through the infection of Agrobacterium rhizogenes strain (A4) from shoot tips and leaves of Rehmannia elata N. E. Brown ex Prain (Orobanchaceae). Seven lines of hairy roots were selected on the basis of morphology and biomass increase in liquid Woody Plant Medium (WPM) supplemented with sucrose (30 g/L) without growth regulators. The transgenic status of the roots was confirmed by reverse-transcriptase polymerase chain reaction (RT-PCR) using rolB and rolC specific primers. After 30 days of growth the highest fresh weight (FW) and dry weight (DW) were determined in the S1 hairy root line (9.97 g/flask and 0.88 g/flask, respectively). UHPLC was then used to measure the accumulation of iridoid glycosides (aucubin, harpagide, harpagoside) and phenylethanoid glycosides (verbascoside and isoverbascoside) in selected hairy root lines. Among the iridoid glycosides, the highest amounts of aucubin (0.2 mg/g DW) and harpagide (1.57 mg/g DW) were detected in the S1 line, and harpagoside (0.09 mg/g DW) in the L14 line. Among the phenylethanoid glycosides, the highest levels of verbascoside (17.35 mg/g DW) and isoverbascoside (˜ 2 mg/g DW) were identified in the S1 root line. Catalpol, catalposide and loganin could not be detected in any tested hairy root line.

Resection margins obtained with patient-specific instruments for resecting primary pelvic bone sarcomas: A case-control study

BackgroundLimb salvage surgery for pelvic bone sarcoma carries a very high risk of local recurrence. Patient-specific instruments (PSIs) have shown promise for obtaining tumour-free resection margins. However, no data are available on medium-term outcomes including local recurrence rates after PSI-guided resection. The objectives of this case-control study were to determine whether PSI-guided resection: 1) was associated with a lower local recurrence rate, 2) allowed a shorter operative time, 3) was associated with better-quality allograft reconstruction. HypothesisPSI-guided resection decreases the local recurrence rate by improving the resection margins in patients with primary pelvic bone sarcomas. Patients and methodsPSI-guided resection was performed in 9 consecutive patients (cases) with primary pelvic sarcomas (chondrosarcoma, n=3; Ewing's sarcoma, n=3; osteosarcoma, n=1; fibrosarcoma, n=1; and radiation-induced sarcoma, n=1). Age ranged from 11 to 63 years. Outcomes were compared to those in a historical control group of 19 patients with primary bone sarcomas who underwent resection surgery in the same hospital without PSI guidance. The case and control groups were similar regarding age, sex distribution, and follow-up duration. The local recurrence rate and operative time were compared between the two groups. Resection margins were classified as R0, R1, or R2. The quality of allograft reconstruction, which was performed in 7 of the 9 cases, was assessed. ResultsAfter a mean follow-up of 52 months (range, 30–90 months), none of the cases had experienced local bone or soft-tissue recurrences, compared to 7 of the 19 controls (p=0.03), in whom mean follow-up was 62 months (range, 24–134 months). Bone resection margins were R0 in 8 cases; in the remaining patient, R1 resection was performed deliberately to preserve an S1 root. All 9 cases had R0 soft-tissue resection margins. In the control group, bone resection margins were R0 in 13 patients, R1 in 5 patients, and R2 in 1 patient (p=0.47). Mean operative time was similar in the cases (612 minutes [range, 435–854 minutes]) and controls (633 minutes [range, 420–990 minutes]) (p=0.87). In the 7 patients who underwent pelvic allograft reconstruction, allograft contact in the defect and osteosynthesis stability were deemed satisfactory by the surgeon. DiscussionThe lower local recurrence rate in the cases demonstrates that the improved resection accuracy provided by PSIs directly influences the risk of local recurrence. In addition, the R0 bone margins in 8 cases establishes that PSIs are effective in improving resection accuracy. Level of evidenceIII, case-control study.

Predeterminative role of Onuf's nucleus ischemia on mesenteric artery vasospasm in spinal subarachnoid hemorrhage: A preliminary experimental study

Although posttraumatic mesenteric artery ischemia is attributed to various etiologies, sacral parasympathetic network/mesenteric artery relations have not been studied so far. The primary objective of this study is to elucidate whether there is a relationship between Onuf's nucleus ischemia and mesenteric artery vasospasm following subarachnoid hemorrhage (SAH). This study was conducted on 22 rabbits. The animals were grouped as follows: 5 of animals control, 5 SHAM which saline was given, and 12 animals study group that was homologous blood injected into the spinal subarachnoid space at the Lı level. Neurodegeneration in Onuf's nucleus, axonal degeneration of S2 roots, and mesenteric arteries vasospasm indexes (VSI; Wall surface/Lumen surface), brachias of mesentery arteries in various tissues and ischemic mucosal changes of intestines of all animals were determined histopathologically. Important degenerative changes were detected in axons in S2 roots and Onuf's nucleus in severe mesenteric artery vasospasm observed. The mean degenerated neuron density of Onuf's nucleus (n/mm3), degenerated axon density in S2 roots (n/mm2), and VSI values of mesenteric arteries of control, SHAM, and study groups were estimated as 5.00±1.58, 4.00±1.58, 1.76±0.13; 18.29±4.31, 11.00±2.24, 2.23±0.20; and 135.21±30.75, 117.33±22.11, 2.81±0.44, respectively. Statistical analyses between the VSI values, mucosal ischemic changes degenerated neurons in Onuf's nucleus, and axons in S2 levels were meaningful (p<0.005). We interestingly noticed that Onuf's nucleus-S2 roots complex degeneration plays an important role in mesenteric artery vasospasm and the development of intestinal ischemic mucosal changes following SAH which has not been extensively mentioned in the literature.

Correlation Between Clinical And Magnetic Resonance Imaging Findings In Patients With Lumbosacral Radiculopathy

Low back pain accounts for a large amount of loss of productivity in the workforce. When the low back pain extends into the lower limb along the distribution of a dermatome then radiculopathy is said to be present. Although most people experience back pain during their lifetime, only a fraction experience lumbosacral radiculopathy as a consequence of nerve root compression or irritation. Almost 5% males and 2.5% females experience lumbosacral radiculopathy at some time in their lifetime. Magnetic resonance imaging (MRI) is the preferred investigation for the diagnosis of lumbosacral radiculopathy. So, in the evaluation of a patient of lumbosacral radiculopathy is essential to correlate clinical symptoms and signs with the finding detected in the MRI to arrive at a correct diagnosis and arrange an appropriate management. So this study was done to see the correlation between clinical and MRI finding of radiculopathy at different nerve root level in patients with lumbosacral radiculopathy. It was a cross sectional descriptive study. All 40 patients of lumbosacral radiculopathy who were presented to Rajshahi Medical College Hospital during the study period from 01/11/2011 to 30/10/2012 were included in the study. There were 30 males and 10 females having an M: F ratio of 3:1. Mean age of total patients 43 + 14.74 years. 67.5% patients were between 20 to 50 years and 60% patients were performing heavy work. 67.5% patients had unilateral involvement while 32.6% patients had bilateral involvement. 72.5% patients had muscle weakness and 27.5% had no muscle weakness. 67.5% patients had sensory impairment and 32.5% had no sensory involvement. Knee jerk changes were present in 60% patients and ankle jerk changes in 66.66% patients. As expected 52.18% had L5 and 32.61% had S1 radiculopathy. The difference in clinical and MRI detection of root involvement was statistically significant (p value &lt; 0.05) in both sides at L4, L5 and S1 root levels but there was no significant difference at the L3 root level (p value 1.00) Intervertebral disc herniation was the commonest cause of lumbosacral radiculopathy (72.32%) and second common cause was spinal canal stenosis (19.44%). Others are intervertebral disc budging (61.52%), disc protrusion (23.08%) and disc extrusion (15.38%). Correlation between clinical severity and MRI grading of lumbosacral radiculopathy which was statistically significant. So, it is concluded that clinical findings correlate well with MRI finding, but all MRI abnormalities need not have a clinical significanceTAJ 2015; 28(1): 32-39