Sacral Dermatomes Research Articles

1. Lumbosacral radicular pain.

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

Herpes Zoster Infections in Solid-Organ Transplant Recipients.

Herpes zoster infections can be complicated and mortal in solid-organ transplant recipients. In our study, we investigated herpes zoster infections in solid-organ transplant recipients. UntilJune 2022, our center has performed 3342 kidney, 708 liver, and 148 heart transplants.Herpes zosterinfections were investigated in 1050 adult solid-organ transplant recipients from January 1, 2011, to June 31, 2022. We studied 44 patients diagnosed with herpes zoster infections. Of the 44 patients with herpes zoster, 32 had kidney, 7 had heart, and 5 had liver transplant procedures. Crude incidence rate was 5.2%.,with 9.7% being heart, 5.1% being kidney, and 3.9% being liver transplant recipients; 72.7% were male patients. The median age was 47.5 years, and 61% of patients were aged >45 years. Postherpetic neuralgia was significantly higher in patients older than 45 years (P = .006). The median duration to infection posttransplant was 16.5 months. The dermatomes of patients were 43.2% thoracic. Sacral dermatome involvement was significantly higher in heart transplant patients than in other transplant recipients (P = .015). We reviewed specific findings of the Tzanck test in 36.4% of the patients. There was concomitant infection in 15.9% of the patients, and 6.8% had pneumonia. Acute neuritis was more common in kidney transplant recipients (65.6%). The mean duration of acute neuritis/neuralgia was longest in liver transplant recipients (13.5 months; P = .047). Postherpetic neuralgia was detected as high as 24%. Early specific and supportive treatmentis important for transplant recipients with herpes zoster infections. Appropriate antiviral prophylaxis regimens and vaccination strategies for varicella zoster (chickenpox) and herpes zoster infections should be implemented in the vaccination schedule of solidorgan transplant candidates to prevent herpes zoster infections and complications.

The clinical course of herpes zoster is similar in immunocompetent and immunocompromised paediatric patients.

We aimed to compare the clinical manifestation of HZ in immunocompetent and immunocompromised children. Medical charts of all consecutive children hospitalized and/or consulted in the Regional Hospital for Infectious Diseases in Warsaw due to HZ were retrospectively analysed. Age, history of varicella, time interval between varicella and HZ, underlying diseases, immunosuppresive therapy, dermatome involvement and HZ complications were analyzed in both groups. In total 152 children were included in the analysis, 56 (36.84%) of them were hospitalsed, whereas 96 (63.16%) were consulted and discharged home due to good general condition. The median age was 10 years (IQR 5.75-12), there were 73 (48.03%) boys and 79 (51.97%) girls. In 16/152 (10.5%) one or more complications occurred, including: skin bacterial superinfection (16/17, 94.2%), sepsis (1/17, 5.9%), meningitis (1/17, 5.9%). Thoracic dermatomes were the most commonly affected (81/152, 53.29%). Most of the children didn't have any immunodeficiencies 118/152 (77.6%), and 34/152 (22.4%) of them were immunocompromised (and had been treated with intravenous acyclovir). The clinical picture of the disease was similar in both groups (Table 1). However, immunocompromised children more often had sacral dermatomes affected (5/35, 14.3% vs. 1/117, 0.9%, p < 0.001), and less often thoracic dermatomes were involved in this group (12/35, 34.3% vs. 69/117, 59%, p = 0.0102). To conclude, herpes zoster occurs in both immunocompetent and immunocompromised children. Clinical manifestations are similar. Serious complications, although uncommon, affect not only immunocompromised patients but also otherwise healthy children.

(040) A Case Report of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia Secondary to Lumbar Facet Cyst-Induced Sacral Radiculopathy Treated by Lumbar Endoscopic Spine Surgery

Abstract Introduction Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD), characterized by distressing, abnormal genito-pelvic sensations, especially unwanted genital arousal, may be triggered by pathology in Region 3, the cauda equina. Sacral radiculopathy is an inflammatory irritation of the S2-S3 nerve roots in the cauda equina, formed by convergence of pelvic, pudendal, and sciatic nerves and clinical symptoms that involve the sensory fields of these nerves. In a subgroup of patients, both cauda equina Tarlov cyst-induced sacral radiculopathy and lumbosacral annular tear-induced sacral radiculopathy have been reported to trigger PGAD/GPD, and in both conditions, endoscopic spine surgery has been shown safe and effective. Lumbar facet cysts, most common at the L4-L5 level, arise from lumbar zygapophyseal joints and can cause sacral radiculopathy. Thus, it is possible that lumbar facet cyst-induced sacral radiculopathy may be a trigger for PGAD/GPD. Objective To report one case of PGAD/GPD secondary to lumbar facet cyst-induced sacral radiculopathy, successfully treated with lumbar endoscopic spine surgery (LESS). Methods A 55-year old woman with a long history of PGAD/GPD presented to our spine-sexual medicine program for biopsychosocial assessment and treatment using our multidisciplinary management algorithm: Step A) detailed psychosocial and medical history; Step B) non-invasive assessments for sacral radiculopathy; Step C) targeted diagnostic transforaminal epidural spinal injection (TFESI) resulting in temporary clinically significant reduction of PGAD/GPD symptoms; Step D) surgical intervention with LESS and post-operative multidisciplinary follow-up. The patient was diagnosed with PGAD/GPD from lumbar facet cyst-induced sacral radiculopathy and underwent LESS for an L4-5 facet cyst. Results This 55 year old cisgendered woman had multiple painful spontaneous orgasms, shooting sharp pains that felt “like a bruise” going up the inside of her vagina, hypersensitivity of her vulva, clitoris, vagina, urethra and anus, along with constant symptoms of arousal and urinary urgency. These began in 2008 after her second childbirth. Her PGAD symptoms worsened over the last 2 years. She experienced sensations of pins and needles in her right buttocks, front of her left thigh, and down both legs into feet and toes. She also had severe constipation and restless leg syndrome. Neurogenital testing, including quantitative sensory testing, sacral dermatome testing and bulbocavernosus reflex latency testing, were all abnormal consistent with sacral radiculopathy. Region 1 anesthesia testing for vestibular pain showed persistent PGAD/GPD symptoms despite numbness on vestibular cotton swab testing. Pudendal nerve testing was negative. It was thus hypothesized that her PGAD/GPD trigger was closer to the central nervous system. Her MRI showed an L4-5 facet cyst. A TFESI with anesthetic was positive with temporary symptom reduction. She underwent LESS to excise the facet cyst and was discharged the same day. At early post-operative follow-up, she is PGAD-free. She no longer has irritative bladder symptoms, sciatica, restless leg syndrome, or pins and needles, and her constipation symptoms have improved. Conclusions Of the many recognized triggers for PGAD/GPD, we report for the first time a patient diagnosed with lumbar facet cyst-induced sacral radiculopathy after a multidisciplinary step-care management algorithm evaluation. She experienced marked improvement with lumbar endoscopic spine surgery. Disclosure No

A Case of Penile Herpes Zoster

Introduction: Herpes zoster (HZ) manifests as vesicular lesions typically involving thoracic dermatomes and rarely sacral dermatomes. Here, we present the case of a 32-year-old immunocompetent man with an atypical presentation of HZ misdiagnosed as herpes simplex virus (HSV). Case presentation: A 32-year-old man first presented with an erythematous rash with increasing pain severity on the right side of the glans penis involving the S2–S3 dermatomes. Repeated polymerase chain reaction (PCR) tests yielded negative results for both HZ and HSV. The appearance of vesicular lesions on the penis led to an initial misdiagnosis of HSV, causing a great emotional burden on the patient. Discussion: HZ occurs uncommonly in the sacral dermatomes. The clinical manifestations of HSV and HZ are similar and must be distinguished via careful diagnostic approaches using PCR testing. The unique symptoms of HZ are unilateral vesicular lesions and post-herpetic neuralgia. Conclusion: Penile HZ should be considered in patients presenting with unilateral, localized vesicular lesions.

"Neuro-Fiber Mapping": An Original Concept of Spinal Cord Neural Network Spatial Targeting Using Live Electrostimulation Mapping to (Re-)Explore the Conus Medullaris Anatomy.

Spinal cord (SC) anatomy is often assimilated to a morphologically encapsulated neural entity, but its functional anatomy remains only partially understood. We hypothesized that it could be possible to re-explore SC neural networks by performing live electrostimulation mapping, based on "super-selective" spinal cord stimulation (SCS), originally designed as a therapeutical tool to address chronic refractory pain. As a starting point, we initiated a systematic SCS lead programming approach using live electrostimulation mapping on a chronic refractory perineal pain patient, previously implanted with multicolumn SCS at the level of the conus medullaris (T12-L1). It appeared possible to (re-)explore the classical anatomy of the conus medullaris using statistical correlations of paresthesia coverage mappings, resulting from 165 different electrical configurations tested. We highlighted that sacral dermatomes were not only located more medially but also deeper than lumbar dermatomes at the level of the conus medullaris, in contrast with classical anatomical descriptions of SC somatotopical organization. As we were finally able to find a morphofunctional description of "Philippe-Gombault's triangle" in 19th-century historical textbooks of neuroanatomy, remarkably matching these conclusions, the concept of "neuro-fiber mapping" was introduced.

Case report: a rare case of Herpes zoster Ophthalmicus with simultaneous impairment of lumbar and sacral dermatomes

Herpes zoster (HZ) occurs as a result of the reactivation of varicella-zoster virus and is characterized by neuralgic pain, constitutive symptoms, pruritus and dysesthesia along nerve pathways. Vesicles on an erythematous base in a dermatome can be identified, and vision loss may occur in cases of ocular involvement. HZ is clinically diagnosed and treated with antivirals. This study aims to report a rare case of HZ simultaneously affecting the ophthalmic branch of the trigeminal nerve and the lumbar and sacral dermatomes. The patient was clinically cured after treatment with acyclovir for 7 days and did not present other complications.

The Initial Subjective Sensory Change in the Dermatome During Intrathecal Injection of Plain Bupivacaine Predicts the Spread of Sensory Blockade: A Prospective Multi-Level Modeling Study.

BackgroundPredicting the spread of anesthesia after intrathecal injection of plain local anesthetics is challenging owing to both patient and anesthesiologist-related factors. ObjectivesThis study aimed to examine the initial patient-reported sensory changes during intrathecal injections and used multi-level analyses to examine the relationships between these changes and other major factors affecting the spread of anesthesia.MethodsThe participants were 120 consecutive patients with the American Society of Anesthesiologists status I and II, who were scheduled for open repair of inguinal hernias under spinal anesthesia. Lumbar puncture was performed at the midline of the L3 - L4 vertebrae and 3 mL of 0.5% isobaric bupivacaine was administered at 0.25 mL/s. The onset, dermatome, and side of the initial subjective sensory changes (ISSCs) were assessed by patient report. The extent of sensory loss to ice and pinprick stimuli, the degree of motor block in lower extremities, blood pressure, and heart rate were examined at 5-minutes intervals for 20 minutes after intrathecal injection.ResultsAll patients reported ISSCs after 9 (4, 18) seconds [median (minimum, maximum)] of the intrathecal injection onset. In 66.7% of the patients, ISSCs occurred in the L1 - L5 dermatomes. Three patients experienced pain during the early intraoperative period, and described ISSCs in the sacral dermatome. Height, mean blood pressure, and ISSCs were significantly correlated with sensory loss. Faster onset, lower dermatome, and floor-side of ISSCs predicted a narrower area of sensory loss, with dermatome as the most important indicator.ConclusionsOur findings demonstrate that ISSC, primarily based on dermatome, is a significant predictor for spinal anesthesia spread.

021 The Role of Office-Based Somatic and Autonomic Neuro-Genital Testing of Persistent Genitourinary Numbness in Women

In women with sexual dysfunction, a bothersome/distressing symptom is persistent numbness in the genitourinary region, the clitoris, vagina and urethra. Women with persistent numbness often find it difficult to feel their clitoris when touched, or feel objects placed within their vagina, or feel urine flowing in their urethra. This symptom often leads to orgasmic dysfunction and limited sexual pleasure. Using office-based neuro-genital testing, we examined the integrity of the somatic and autonomic neurologic pathways of genitourinary sensation to better understand the etiology of female genitourinary sensory impairment. Office-based neuro-genital testing includes quantitative sensory testing, sacral and foot dermatome testing, bulbocavernosus reflex latency testing, vaginal pelvic afferent nerve testing and urethral pelvic afferent nerve testing. Quantitative sensory testing measures somatic vibration, cold, and heat perception threshold values in the glans clitoris, right and left inner surface of labia minora, and uses the right pulp index finger threshold values as the control. Sacral and foot dermatome testing measures somatic vibration perception in the right and left gluteal, thigh, calf, heel, arch, medial and lateral aspects of the foot, using the right pulp index finger threshold values as the control. Bulbocavernosus reflex latency testing with electromyographic monitoring of the external anal sphincter muscle contraction measures the integrity of the somatic sensory and motor neural pathways in response to mechanical stimulations of the glans clitoris. The vaginal pelvic afferent neural pathway test measure visceral awareness of distension of an anorectal (up to 60 ml) balloon within the vagina. The urethral pelvic afferent neural pathway test measure visceral awareness of distension of a Foley catheter (up to 0.4 ml) balloon within the urethra.

Dermatomal Versus Mixed Somatosensory Evoked Potentials in the Diagnosis of Lumbosacral Spinal Canal Stenosis

The existing literature on the use of dermatomal somatosensory evoked potentials in lumbosacral spinal canal stenosis is limited. The goal of this study was to evaluate the role of dermatomal against mixed tibial somatosensory evoked potential (SEP) as a complementary procedure to imaging studies in the diagnosis of lumbosacral stenosis. Thirty patients with clinically and radiologically diagnosed lumbosacral stenosis and 20 normal individuals were enrolled in the study. The study was ethically approved, and informed consent for participation was provided. All participants underwent bilateral mixed tibial and dermatomal SEP study of the third (L3), fourth (L4), fifth lumbar (L5), and first sacral (S1) dermatomes. N45, N25, N20, and N10 tibial SEP waves were measured from four channels, whereas dermatomal waves were measured from cortical recording. Peak latency and amplitude of each wave were calculated. The cutoff value of the dermatomal S1 latency showed the highest sensitivity and specificity percentages (81.7 and 82.5, respectively), followed by L5 and N25. N25-N45 interpeak latency showed the lowest sensitivity and specificity. All L5, S1, L4, and N25 latency cutoff values presented highly significant differences between affected sides and controls (P < 0.0001), followed by N45 and N20. The amplitude cutoff values of SEP waves showed equivocal sensitivity and specificity percentages. Somatosensory evoked potential studies can be used as a supplementary test for the diagnosis of lumbosacral stenosis, with the dermatomal studies being more valuable expressing multiple root abnormalities. S1 dermatomal wave latency has the highest diagnostic value, followed by L5, N25, and then L4 latencies.

030 Curing Patients with Neurogenic Sexual Dysfunction through a Novel Collaborative Protocol Incorporating Minimally-Invasive Spinal Surgery: Largest Known Retrospective Series

Persistent genital arousal disorder (PGAD) was first described in 2001. Pathophysiology was elusive, treatment symptom-based, and cures rare. In 2012 Komisaruk related PGAD to radiculitis of sacral spinal nerve root (R-SSNR) from Tarlov cysts. It was subsequently hypothesized that other neurogenic sexual dysfunctions could be related to various cauda equina based sacral and lumbar pathologies resulting in R-SSNR. Women presenting with PGAD underwent diagnostic neurogenital testing: sacral dermatome, genital biothesiometry, and bulbocavernosus reflex latency testing. If abnormal, then lumbar/sacral MRI studies assessed for a treatable spine abnormality (TSA). If a TSA was found a targeted transforaminal epidural spinal injection (TFESI) was performed to ascertain PGAD symptom reduction. In appropriate patients minimally-invasive, computer-navigated, spine surgery was performed. Over the past 3 years 30 women presented with PGAD. About 65% have gone through the protocol. Ten women (mean age 44 years, range 18-67) have undergone surgery. Eight women had >2 month follow-up and are included here. Pathophysiologies included annular tear (n=5), spondylolisthesis (n=1), facet cyst (n=1), and spinal stenosis (n=1). Seven patients underwent minimally-invasive laser endoscopic spine surgery, and 1 minimally-invasive spinal reconstruction and fusion. Of the 8 patients who underwent surgery, 5 had a Patient Global Impression of Improvement score of 1 (very much better), 1 scored a 3 (a little better) and 2 scored a 4 (no change in symptoms). Quality of life regarding sexual function has already been achieved in 63%, although follow up has been less than half a year in many of the cases. There were no surgical complications. This same protocol has been used to treat other sexual dysfunctions with similar results.

PD54-12 CURING PATIENTS WITH NEUROGENIC SEXUAL DYSFUNCTION THROUGH A NOVEL COLLABORATIVE PROTOCOL INCORPORATING MINIMALLY-INVASIVE SPINAL SURGERY: LARGEST KNOWN RETROSPECTIVE SERIES

You have accessJournal of UrologySexual Function/Dysfunction: Female1 Apr 2018PD54-12 CURING PATIENTS WITH NEUROGENIC SEXUAL DYSFUNCTION THROUGH A NOVEL COLLABORATIVE PROTOCOL INCORPORATING MINIMALLY-INVASIVE SPINAL SURGERY: LARGEST KNOWN RETROSPECTIVE SERIES Eric Biewenga, Sue Goldstein, Vera Trofimenko, Barry Komisaruk, Jennifer Hanley, Choll Kim, and Irwin Goldstein Eric BiewengaEric Biewenga More articles by this author , Sue GoldsteinSue Goldstein More articles by this author , Vera TrofimenkoVera Trofimenko More articles by this author , Barry KomisarukBarry Komisaruk More articles by this author , Jennifer HanleyJennifer Hanley More articles by this author , Choll KimCholl Kim More articles by this author , and Irwin GoldsteinIrwin Goldstein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2620AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Persistent genital arousal disorder (PGAD) was first described in 2001. From 2001 - 2012, the pathophysiology was elusive, treatment was focused primarily on symptom-reduction, and cures of PGAD were rare. In 2012 Komisaruk was the first to describe PGAD secondary to radiculitis of a sacral spinal nerve root (SSNR) from Tarlov cysts. It was subsequently hypothesized that other lumbar spine cauda equina-based pathologies, including annular tears, disc impingements, spinal stenosis, or Facet cysts, could result in radiculitis of a SSNR causing PGAD. METHODS Women presenting with PGAD underwent diagnostic neuro-genital testing including quantitative sensory testing, sacral dermatome testing and bulbocavernosus reflex latency testing. If abnormal, then lumbar/sacral MRI studies assessed for a treatable spine abnormality (TSA). If a TSA was found a targeted transforaminal epidural spinal injection (TFESI) was performed to ascertain robust PGAD symptom reduction. In appropriate patients, minimally-invasive spine surgery was performed. RESULTS Over the past 30 months, 27 women presented with PGAD. Ten women (mean age 44 years, range 18-67) have met pre-operative inclusion criteria based on a multi-dimensional management paradigm and have undergone minimally-invasive surgery. Eight women had >2 month follow-up and are included here. Pathophysiologies included annular tear (n=5), spondylolisthesis (n=1), facet cyst (n=1), and spinal stenosis (n=1). Seven patients underwent minimally-invasive laser endoscopic spine surgery and one underwent minimally-invasive spinal reconstruction and fusion. Of the eight patients who underwent surgery, five had a Patient Global Impression of Improvement score of 1 (very much better), one scored a 3 (a little better) and two scored a 4 (no change in symptoms). Quality of life regarding sexual function has already been achieved in 63%, although follow up has been less than half a year in many of the cases. There were no surgical complications. This same protocol has been used to treat other sexual dysfunctions with similar results. CONCLUSIONS This is the first study, to our knowledge, showing successful surgical treatment of PGAD related to various cauda equina based lumbar pathologies causing radiculitis of a SSNR. A multi-dimensional management paradigm has been developed to help women with PGAD to be cured by minimally-invasive spinal surgery. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1055 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Eric Biewenga More articles by this author Sue Goldstein More articles by this author Vera Trofimenko More articles by this author Barry Komisaruk More articles by this author Jennifer Hanley More articles by this author Choll Kim More articles by this author Irwin Goldstein More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effects of Adding Intrathecal Dexmedetomidine to Hyperbaric Bupivacaine for Saddle Spinal Block in Adults Undergoing Peri-anal Surgeries

Saddle spinal block is the first choice anesthetic technique for adults undergoing peri-anal surgeries. It prevents unnecessary high levels of analgesia and sympathetic block. However, it may not provide prolonged analgesia. This study aims to investigate analgesic effects of dexmedetomidine when added to hyperbaric bupivacaine in saddle spinal block. Fifty otherwise healthy adults scheduled for uncomplicated peri-anal surgery were randomly allocated into two equal groups in this double-blinded study. Group A received hyperbaric bupivacaine five milligrams; group B received hyperbaric bupivacaine five milligrams plus dexmedetomidine five micrograms intrathecally. Patients remained seated for ten minutes. Time to first analgesic request by patients was the primary end point. Onset and extent of sensory block, and, magnitude and duration of motor block were assessed. Post-operative analgesic consumption and side effects were studied for 24 hours. Student's t-test for quantitative variables and Chi-square test for categorical variables were used for statistical analysis. Patients in group B had a significantly prolonged duration of analgesia (group B, 501 ± 306 minutes; group A, 284 ± 58 minutes) and significantly reduced analgesic requirement than patients in group A. Sensory block in first sacral dermatome appeared significantly earlier in group B. Peak sensory block, magnitude of motor block, and side effects were not significantly different between groups A and B. Dexmedetomidine as an intrathecal adjuvant to hyperbaric bupivacaine in saddle spinal block prolongs duration of analgesia and decreases analgesic requirement with no added side effects.

Total Spinal Anesthesia Failure: Have You Assessed the Sensory Anesthesia in Sacral Dermatomes?

(Anesth Analg. 2017;124(5):1674–1677) Spinal anesthesia failure (SAF), which often results from intrathecal local anesthetic (LA) maldistribution, is sometimes managed with repeated spinal anesthesia (SA). In this brief report, the authors suggested that evaluation of sacral dermatomes before repeating SA can aid in the differentiation of total from partial SAFs, which in turn would lower the risks of neurotoxicity and safely guide subsequent anesthetic management.

Neostigmine Combined or Not With Lidocaine for Epidural Anesthesia in Mares

Only a few studies have examined the effect of neostigmine combined with lidocaine on epidural anesthesia in gelding horses. The purpose of this investigation was to evaluate clinical effects, ataxia, and the sensory block duration caused by adding neostigmine to epidural lidocaine in mares. Three independent treatments including neostigmine (NEOST), 2% lidocaine (LIDO), or 2% lidocaine combined with neostigmine (LIDO + NEOST) were administered to six mares using epidural catheters. Each animal received all treatments. A cutaneous pinprick nociception test with fine needle was used in perianal, sacral, and lumbar dermatomes in both antimeres. The response (attempt to kick, movement of the limbs, tail, or head toward the stimulus) was assessed immediately before and after each treatment (every 15 minutes in the first hour, and then every 30 minutes thereafter until the animal would go back to basal response). Analysis of variance (P < .05) was used to compare the treatment responses. The NEOST group did not show sign of anesthesia in any of the dermatomes. The LIDO and LIDO + NEOST groups showed sensory block of the perianal and sacral dermatomes, but not of the lumbar dermatome. The mean duration of anesthesia on perineal dermatomes was 58.4 minutes using lidocaine alone and 64.2 minutes when neostigmine were added to lidocaine with no significant difference between these two treatments (P > .05). No relevant changes in clinical and behavioral parameters were observed. In conclusion, adding neostigmine to lidocaine has not brought any relevant benefits to the epidural anesthesia in clinically normal mares.

Total Spinal Anesthesia Failure: Have You Assessed the Sensory Anesthesia in Sacral Dermatomes?

Intrathecal local anesthetic maldistribution is a well-known cause of spinal anesthesia failure (SAF). This could potentially result in sensory blockade restricted to the sacral dermatomes. We sought to determine the overall incidence of SAF and the role of sacral dermatomes in differentiating between total and partial failures. Of the 3111 spinals prospectively examined, 194 (6.2%) were classified as failures. Of the 72 presumed total failures based on the initial assessment, evaluation of the sacral dermatomes revealed sensory blockade in 32 (44%; 95% confidence interval, 32.7%-56.6%). Sacral dermatome assessment after SAF may be important in safely guiding subsequent anesthetic management.

Finding an Answer: Comments on a Randomized Trial of Epidural Glucocorticoid Injections for Lumbar Spinal Stenosis.

Recently, Friedly et al. published a study on the effectiveness of epidural injections of steroids (ESIs) for lumbar spinal stenosis (LSS) [1]. Because of its apparent implications for clinical practice, this study attracted comments both in the professional [2] and lay press [3]. However, the study prompts reflection on a number of issues that extend beyond the conventional appraisal of a study. Those issues pertain to how physicians think about a condition, how it should be treated, and how to best assess the effectiveness of that treatment. The following article addresses those issues in the interest of informing physicians about how contemporary practices are confounded by lack of diagnostic discipline, and how this makes the conduct of controlled trials complicated and, therefore, makes the results difficult to assess. The cardinal issues are the symptoms of LSS; the diagnosis of LSS; the rationale for treatment; the consequent appropriate selection of patients; the outcomes assessment, either in practice or in a study including the reporting of those outcomes; and the need for rigorous control of the technical performance of the therapeutic intervention. Each of these issues has a critical bearing on appraising not only the literature on LSS, but also on how physicians treat this condition in conventional practice. The literature is profuse with heterogeneity in symptomology related to LSS. While there is no consensus in the current literature on acceptable LSS symptoms, the most commonly quoted symptoms are neurogenic claudication, radicular pain, and low back pain (LBP). Additional symptoms commonly mentioned in literature were fatigue and loss of power in the legs, anesthesia, and a feeling of numbness in the sacral dermatomes. In an attempt to achieve consensus, Katz et al. in 1995 published symptoms most strongly associated with the diagnosis of LSS (likelihood ratio ≥ 2), …

Herpes zoster manifesting as isolated oral thin leukoplakia in an immunocompetent host

Herpes zoster (HZ) has long been considered as a disease of immunocompromised elders. It is usually caused by the revitalized varicella; remaining dormant within the sensory ganglia of sacral dermatomes since an early childhood stint at chickenpox. Trigeminal nerve is rather uncommonly infested. Characteristic zoster lesions appear as unilateral mucocutaneous vesiculobullous rashes, preceded by intense radiating neuralgic pain for few days. This article emphasizes on an immunocompetent man, in his early sixties, presenting with two painful leukoplakic patches over buccal mucosa as the sole manifestation of HZ.

Lateral medullary infarction masquerading as involvement of spinal cord

Dear Editor, Unilateral sensory impairment below the dermatome usually suggests involvement of the spinal cord. Here, we describe a patient presenting with impaired pain and temperature sensation below the right-side Th8 dermatome due to left lateral medullary infarction. An 86-year-old woman visited our clinic presenting with numbness in her right lower leg. Her past medical history included hypertension, diabetes mellitus, dyslipidemia, hyperthyroidism, and postoperative state after the removal of a hemangioblastoma on the right cerebellum. Her consciousness was clear. Vital signs and general physical examination were normal. Neurological examination revealed deficits in pain and temperature sensation below the Th8 dermatome on the right trunk and leg (Fig. 1a). She showed dysmetria of the right arm and a wide-based gait, but both had been present for years since cerebellar tumor surgery. Motor paralysis or Horner’s syndrome was not seen. We initially suspected that she had involvement of the thoracic spinal cord. However, spinal MRI demonstrated no abnormality in the spine or spinal cord. Brain MRI revealed a small infarction in the left lateral medulla oblongata by diffusion-weighted image (Fig. 1b) and fluid attenuation inversion recovery (Fig. 1c). Magnetic resonance angiography showed an atherosclerotic stenosis at left vertebral artery (Fig. 1d), and high-echoic plaques were found in the bilateral commonand internal-carotid arteries by carotid ultrasonography. Echocardiography and 24-h EEG were normal. The patient was clinically diagnosed with atherothrombotic infarction on the basis of NINDS III classification [1]. Antiplatelet therapy was started subsequently, and the sensory impairment gradually resolved. The lateral spinothalamic tract conveys pain and temperature sensation in the contralateral body and is arranged topographically in the medulla oblongata. Afferents from caudal areas are located in the lateral portions of the tract [2] (Fig. 1e). In our case, the lesion was mostly restricted to the left lateral portion of the spinothalamic tract, affecting sensory fibers conveying superficial sensory information from the sacral, lumbar, and thoracic (to Th8) dermatomes on the right side. Accordingly, the sensory impairment was seen below the right Th8 dermatome. Reports of such patients presenting with sensory deficits in a dermatomal

Sacral Herpes Zoster Associated with Voiding Dysfunction in a Young Patient with Scrub Typhus.

When a patient presents with acute voiding dysfunction without a typical skin rash, it may be difficult to make a diagnosis of herpes zoster. Here, we present a case of scrub typhus in a 25-year-old man with the complication of urinary dysfunction. The patient complained of loss of urinary voiding sensation and constipation. After eight days, he had typical herpes zoster eruptions on the sacral dermatomes and hypalgesia of the S1-S5 dermatomes. No cases of dual infection with varicella zoster virus and Orientia tsutsugamushi were found in the literature. In the described case, scrub typhus probably induced sufficient stress to reactivate the varicella zoster virus. Early recognition of this problem is imperative for prompt and appropriate management, as misdiagnosis can lead to long-term urinary dysfunction. It is important that a diagnosis of herpes zoster be considered, especially in patients with sudden onset urinary retention.