Sacral Nerve Roots Research Articles

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.

126 A Novel Collaborative Protocol for Successful Management of Genito-Pelvic Dysesthesia Mediated by Radiculopathy of Sacral Spinal Nerve Roots Within the Cauda Equina: Four Year Experience

In 2012, Komisaruk et al introduced the concept that neurologic-based women’s sexual health issues, genito-pelvic dysesthesia (GPD), could be caused by radiculopathy of sacral spinal nerve roots within the cauda equina. Over the last 4 years, to more effectively manage patients with suspected cauda equina pathology, a robust collaboration among sexual medicine, spine surgery and neurophysiology disciplines has been established.

Evaluation of Outcome of Timing of Surgical Intervention on Cauda Equina Syndrome

Introduction: Cauda equina syndrome (CES) is a rare clinical entity caused by compression of lumbar and sacral nerve roots resulting in various neurological dysfunctions. Early diagnosis of the syndrome and timely intervention is required to prevent permanent disability. 
 Methods: This is a retrospective study conducted from January 2013 to December 2017 in a tertiary care centre in Kathmandu, Nepal. All the cases meeting the inclusion criteria were included in the study. Patients were operated using posterior open discectomy and the outcome was evaluated at two weeks , one month, three months, six months and one year.
 Result: Total number of patients meeting the inclusion criteria was 10, two females and eight males with a mean age of 40.30 + 6.58 years. The mean time for onset of symptom to timing of surgery was 142 hrs. VAS for leg improved from 5.90 + 0 .738 to 0.70 + 0.483 and VAS for back pain improved from 3.20 + 1.476 to 0.5 + 0.572 post operatively. There was improvement in sensory and motor function in all the cases. Bowel and bladder function improved in all the cases postoperatively at the time of final follow up. Sexual function was impaired in six patients preoperatively but postoperatively four had improved and two patients had poor result at the time of final follow up.
 Conclusions: Timing of surgery may not be the most important determining factor for the outcome of the CES. Surgical decompression in delayed presentation have good clinical outcome in CES.

Long-term rates of bladder dysfunction after decompression in patients with cauda equina syndrome

BACKGROUND CONTEXTCauda equina syndrome (CES) occurs due to compression of the lumbar and sacral nerve roots and is considered a surgical emergency. Although the condition is relatively rare, the associated morbidity can be devastating to patients. While substantial research has been conducted on the timing of treatment, the literature regarding long-term rates of bladder dysfunction in CES patients is scarce. PURPOSEThe aim of this study was to identify long-term rates of bladder dysfunction in CES patients and to compare those rates to non-CES patients who underwent similar spinal decompression. STUDY DESIGN/SETTINGRetrospective database study. PATIENT SAMPLEThe CES cohort was comprised of 2,362 patients who underwent decompression surgery following CES diagnosis with a 5-year follow-up. These patients were matched to 9,448 non-CES control patients who underwent spinal decompression without a diagnosis of CES. OUTCOME MEASURESDiagnosis of bladder dysfunction, surgical procedure to address bladder dysfunction METHODSUsing the national insurance claims database, PearlDiver, CES patients who underwent decompression surgery were identified and 1:4 matched to non-CES patients who underwent similar spinal decompression surgery. The 1-year, 3-year, and 5-year rates of progression to a bladder dysfunction diagnosis and surgical intervention to manage bladder dysfunction were recorded. The CES and non-CES groups were compared with univariate testing, and an analysis of risk factors for bladder dysfunction was performed with multivariate logistic regression analysis. RESULTSA total of 2,362 CES patients who underwent decompression surgery were identified and matched to 9,448 non-CES control patients. After 5 years, CES patients had a 10%–12% increased absolute risk of continued bladder dysfunction and a 0.7%–0.9% increased absolute risk of undergoing a surgical procedure for bladder dysfunction, as compared to matched non-CES patients. Multivariate analysis controlling for age, sex, obesity, tobacco use, and diabetes, identified CES as independently associated with increased 5-year risk for bladder dysfunction diagnosis (odds ratio [OR]: 1.72; 95% confidence interaval [CI] 1.56–1.89; p<.001) and procedure (OR: 1.40; 95% CI 1.07–1.81; p=.012). CONCLUSIONSUnderstanding the long-term risk for bladder dysfunction in CES patients is important for the future care and counseling of patients. Compared to non-CES patients who underwent similar spinal decompression, CES patients were observed to have a significantly higher long-term likelihood for both bladder dysfunction diagnosis and urologic surgical procedure.

Probable Cerebrospinal Fluid Infiltration into the Sacral Nerve Root Sheath and Exudation after Stagnant Retention in It, detected via Magnetic Resonance Imaging and Myelography : A Case Report

Probable Cerebrospinal Fluid Infiltration into the Sacral Nerve Root Sheath and Exudation after Stagnant Retention in It, detected via Magnetic Resonance Imaging and Myelography : A Case Report

Dorsolateral Sacral Plexus: An Anatomical Description

Previous studies demonstrate the rich innervation of the sacroiliac joint by the sacral dorsal rami lateral branches, as well as its link to low back pain and sciatica. However, no study has detailed the terminations of the lateral branches, nor their branching structures lateral to the joint proper. In this study, we investigated the path and connectivity of the dorsal sacral rami and their relationship to the sacroiliac joint and surrounding tissues. 10 cadaveric hemipelvises were carefully dissected to reveal the path and intersections of the nerves as they exit laterally from the sacral foramina. Our dissections revealed a variable network of connectivity, from the S1 dorsal sacral rami to the S4 dorsal sacral rami, that runs laterally to the long dorsal sacroiliac ligament and terminates in a confluence of sacrococcygeal connective tissue. The dorsal rami of the posterior sacral nerve roots form a neural network consistent with a true nervous plexus; we designated the dorsolateral sacral plexus. Connecting with the coccyx, the dorsolateral sacral plexus may provide a putative neurophysiologic conduit between the lumbar spine and pelvis (notably the pelvic floor). Future studies are warranted to determine if the dorsolateral sacral plexus plays a role in lumbopelvic pain or mechanical phenomena.

Risk Factors of Hyperglycemia After Nerve Blockade with Dexamethasone in Non-Diabetes Mellitus Patients: A Cohort Study

BACKGROUND: Glucocorticoids (GCs) are expected to inhibit the synthesis and release of proinflammatory cytokines, which induces local pain. Serious side effects or complications are considered rare with single-dose GC use. However, the amount of systemic absorption and the side effects induced by local GC injections are not well understood. OBJECTIVES: We measured the changes in glucose levels after single-does dexamethasone injection with nerve blockade using a continuous glucose monitoring system (CGMS) in non-diabetes mellitus (DM) patients and investigated the risk factors for hyperglycemia. STUDY DESIGN: This is a cohort study. SETTING: This study was conducted at Gifu University Hospital in Japan. METHODS: Forty-six non-DM patients who underwent elective lumbar or sacral nerve root pulsed radiofrequency or lumbar medial branch of the posterior primary rami conventional radiofrequency with dexamethasone (0.1 mg/kg) were analyzed. The patients underwent monitoring of their interstitial glucose using a CGMS. Hyperglycemia was defined as a blood glucose level ≥ 200 mg/dL. The area under the curve (AUC) where the blood glucose level was over 200 mg/dL was calculated and analyzed. The risk factors of hyperglycemia were determined using an applied ordinal regression model analysis with the AUC as the objective variable and 4 factors (age, body mass index, glucose level just before GC injection, and glycosylated hemoglobin) as explanatory variables. The blood glucose levels were predicted by a nonlinear regression model. RESULTS: The AUC and maximum glucose level were higher on the first day than after the second day. None of the 4 factors were predictors of hyperglycemia. The glucose level before the procedure was associated with the predicted blood glucose level on the first day (P = 0.042). However, the 95% upper confidence limit of the maximum predicted blood glucose level was less than the safety margin. The predicted blood glucose levels returned to the usual level after the second day. LIMITATIONS: First, GCs are metabolized by cytochrome p450 3A4, and it is possible that the inhibition of this pathway decreases the clearance of GCs. Some of our patients were taking medications that influence this cytochrome pathway. Second, we cannot eliminate the possibility of stress-induced hyperglycemia. Finally, we were unable to record the exact meal timing and calories the patients had consumed. CONCLUSIONS: The blood glucose levels were higher than usual on the first day following a local dexamethasone injection, but the levels were not critical in most cases. Because we cannot predict which patients will develop hyperglycemia, we must determine whether or not GCs can be safely administered and inform patients about potential complications. KEY WORDS: Glucocorticoids, hyperglycemia, nerve blockade, non-diabetes mellitus patients

Sacral nerve stimulating on intestinal mucosal immune barrier function of rats with acute complete spinal cord injury

Objective: To study the effects of sacral nerve root stimulation on intestinal mucosal immune barrier function in rat with acute complete spinal cord injury(SCI). Methods: Fifty-six Wistar rats were divided into Sham group(SG n=8), control group(CG 24 、 48、 72 h,n=8), and experimental group(EG 24、 48、 72 h,n=8). In CG and EG, according to Fehlings'method,we transected the spinal cord by the aneurysm clip and implanted electrodes into the third sacral foramina on the right side.We stimulated in intensity 4 V,the frequency of 15 Hz,and the pulse of 210 μs.The stimulation period was 2 hours,with 10 minutes stimulation and 10 minutes rest intermittently,twice a day at 8:00-10:00 am and 6:00-8:00 pm. The intestinal morphology was observed under light microscope and electron microscope. The protein expression levels of A20,NOD2,and CD68 by Western blot . Results: ① SCI caused impaired intestinal epithelial barrier function. The intestinal mucosa appeared different degree of damage in CG group; cell-cell connections between intestinal epithelial cells were destroyed; The escherichia coli and other antigen translocated through the injured epithelial cell , M cells, and the leakage to the lamina propria of intestinal villi, which were improved in EG after stimulation.② The expression of A20 in EG was increased ,which had statistical differences between CG or SG(P＜0.01); the expression ofA20 in CG was decreased, which had statistical differences between SG(P＜0.01).The expression of NOD2 in CG was increased, which had statistical differences between SG(24 h,72 h P＜0.05; 48 h P＜0.01);The expression of NOD2 in EG (48 h ,72 h)was decreased, which had statistical differences between CG(48 h P＜0.01,72 h P＜0.05). The expression of NOD2 in EG had no statistical differences between SG. The expression of CD68 in CG was increased,which had statistical differences between SG or EG(P＜0.01).The expression of CD68 in EG was increased in 24 h and 48 h groups ,which had statistical differences between SG(P＜0.01),but had no statistical differences in 72 h group. Conclusion: Sacral nerve root 3 electrostimulation can rehabilitate the peristalsis of intestine,decrease bacterial amount,reduce inflammatory response, enhance endogenous protection, protect the intestinal mucosal immune barrier function.

Management of Vascular Entrapment with Coexisting Fibrosis on the Sacral Nerve Roots

Study Objective To demonstrate decompression of sacral nerves from aberrant vessels and fibrous tissue located on the plexus. Design Video presentation of two cases. Setting Tertiary center specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 43-year-old gravidity 1 parity 1 female patient presented with dysmenorrhea, dyspareunia and pudendal pain with dysuria. Gynecological examination revealed deep infiltrative endometriosis with rectovaginal nodule and partial obliteration of pouch of Douglas. She had a history of laparoscopic endometriosis surgery with left oophorectomy and was treated with intravascular coil embolization for pelvic congestion syndrome. Case 2: A 41-year-old gravidity 1 parity 1 female patient presented with chronic pelvic pain and left sided sciatic pain with chronic dysesthesia in the dermatome of sciatic nerve without any motor deficit of lower extremity. Gynecological examination revealed deep infiltrative endometriosis and full obliteration of pouch of Douglas. She had a history of multiple laparoscopic and laparotomic operations for endometriosis. Interventions Robot-assisted laparoscopic sacral nerve decompression and dissection of cul-de-sac with rectal nodule shaving (case1) and laparoscopic sacral nerve decompression and dissection of cul-de-sac (case 2). Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. Both patients report significant pain reduction with visual analog scale score. Conclusion Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by an abnormal structure (abnormal vessels, fibrous tissue, tumor, etc.) located on the plexus. Deep infiltrative endometriosis may affect retroperitoneal tissue by causing fibrosis. An abnormal vessel, which is located on the sacral plexus may entrap the roots much easier with coexisting fibrosis. On six moths follow up the visual analog scale score of case 1 and 2 decreased from 10 to 4 and 10 to 3, respectively. Patients are still under surveillance.

Robot-Assisted Laparoscopic Management of Vascular Entrapment of the Sacral Nerve Roots Causing Motor Deficit

Study Objective To demonstrate the robot-assisted laparoscopic decompression approach to treat aberrant vessels entrapping the sacral nerves causing motor deficit. Design Video presentation of two cases. Setting Tertiary unit specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 23-year-old virgin female patient presented with right lower extremity weakness, which had progressed into a limp over the past year and dysmenorrhea with a VAS (visual analog scale) score of 10. Gynecological examination revealed a 2 cm endometrioma on the right ovary. Under neurological examination hypoesthesia on right peroneal and right tibial nerve-dermatomes and chronic denervation of the muscles innervated by L5-S1 were observed. Case 2: A 46-year-old gravidity 3 parity 3 female patient presented with non-menstrual left sciatic pain, which caused difficulties while wearing socks and high heels and climbing up stairs. Magnetic resonance imaging (MRI) revealed dilated vessels on the left sacral nerve roots. Interventions Robot-assisted laparoscopic sacral nerve decompression Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. First patient's electromyography (EMG) result was normal at the 3rd month control. Motor deficit of both patients were eliminated and they both recovered fully. Conclusion Motor deficit or pain radiating (i.e. sciatica) to lower extremities are usually caused by spinal cord problems. However, these symptoms could arise by anatomic structures obstructing the nerves travelling to target organs or by nerve injuries. Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by abnormal vessels crossing over the plexus. Accessing to the sacral plexus between lateral iliac vessels and iliopsoas muscle is crucial and stable instruments are crucial during surgery. Robotic-assisted laparoscopy allows this stability and decrease the possibility of complications. The robotic technique offers, three-dimensional vision, improved maneuverability and enhanced ergonomics in the deepest parts of the pelvis.

S2306 Bad to the Bone: A Rare Case of Fistulizing Disease Extending to the Sacrum

INTRODUCTION: Fistula formation commonly occurs between intestines and other epithelial-lined hollow organs such as the bladder, skin, vagina, or other regions of the gastrointestinal tract. Infrequently, a connection can form between the bowel and the vertebral column and lead to vertebral osteomyelitis. We present the case of a young male with significant abdominal pathology found to have sacral osteomyelitis in the setting of fistula formation between the small bowel and sacrum. CASE DESCRIPTION/METHODS: A 27-year-old male with a history of opioid dependence and abdominal gunshot wound requiring subtotal colectomy with ileo-rectal anastomosis presented with progressive, bloody diarrhea and poor appetite. The patient reported history of previous colonoscopies with balloon dilations of strictures but never diagnosed with inflammatory bowel disease (IBD) or started on any therapies. On exam, the patient was emaciated with multiple clean abdominal scars and diffuse, mild abdominal tenderness. Labs showed microcytic anemia with hemoglobin of 8, elevated fecal calprotectin (402) and CRP (15.1) without leukocytosis, and negative tissue transglutaminase. His stool studies and gastrointestinal pathogen panel were negative for Clostridium difficile or other pathogens. Computed Tomography of the abdomen found enteritis and proctocolitis and concern for possible osteomyelitis of the sacrum and coccyx. Magnetic resonance enterography found multiple entero-colonic fistulas and active inflammatory disease of the small bowel, inflammation of the sacral nerve roots, and concern for fistulization between the small bowel and sacrum. Subsequent flexible sigmoidoscopy found ulcerated friable mucosa and pseudomembranes in the rectum. Pathology showed nonspecific chronic inflammation and was negative for Clostridium difficile. He was started on Rifaximin for empiric treatment of small intestinal bacterial overgrowth with improvement in diarrhea and is planned for further IBD workup to assess the status of his fistulizing disease. DISCUSSION: While most enteric fistulas occur due to prior abdominal surgery complications, 10-15% occur from inflammation and infection associated with Crohn’s disease. Rarely, fistulas can develop between bowel and vertebra, and osteomyelitis may result due to translocation of gut flora from the intestine to the spine via the fistula as seen in our patient. Ultimately, this uncommon presentation should prompt investigation into etiology and use imaging to guide aggressive management.Figure 1.: Rectal ulcer seen on flexible sigmoidoscopy.Figure 2.: MRE showing evidence of a fistula from the small bowel to the sacrum.

Computer navigation assisted tumor surgery for internal hemipelvectomy - Early experience

Internal hemipelvectomy is a surgically challenging entity, owing, among other reasons, to a complex anatomy. The apprehension of an inadequate margin or injury to critical structures adds to the complexity of these major surgical procedures. Computer assisted tumor surgery (CATS) has been increasingly used to improve outcomes of internal hemipelvectomy over the last decade. We analyzed the surgical and postoperative details of first four patients undergoing internal hemipelvectomy with CATS assistance at our institute, the first ever report in an Indian setting. The patients were analyzed for blood loss (mean 1300 ml), operative time (mean 306 min) and hospital stay (mean 7 days). The histopathological margins were free of disease in all the patients, even as the average closest bony margin was 0.9 cm. Sparing of sacral nerve root was made possible by the close yet free margins in two patients. In this retrospective analysis of a small series of patients with computer navigation assisted internal hemipelvectomy, we found this technique to be feasible and effective in achieving the oncological aim of negative margins with preservation of critical structures.

New surgical paradigm for open neural tube defects.

An open neural tube defect (ONTD) features an exposed, unclosed neural plate in the form of an expanded, flat, and frequently hefty neural placode. Traditional philosophy of ONTD repair aims at preserving function at any cost, which often means stuffing the entire thick and unwieldy but non-functional placode into a tight dural sac, increasing the likelihood of future tethering of the spinal cord. The same philosophy of attempting to save the whole perimetry of the placode also sometimes leads to inadvertent inclusion of parts of the squamous epithelial membrane surrounding the placode into the reconstructed product, only to form inclusion dermoid cyst causing further injury to the neural tissues. Lastly, defective closure of the caudal primary neural tube usually results in abolition of secondary and junctional neurulation, leaving a defective conus and sacral nerve roots, clinically presenting in most cases with neurogenic bladder and bowel dysfunction. Preserving this trapped but locally active sacral micturition center, isolated from suprasegmental inhibitory moderation, leads to a spastic, hyperactive, low compliance, and high-pressure bladder predisposing to upstream kidney damage, without benefits of normal bladder function. We report the post-natal surgical treatment of 8 newborn infants with ONTD, in which we resected the non-functional portion of the neural placode identified as such by direct spinal cord/placode and nerve root stimulation, as well as by transcortical evoked motor responses to check for suprasegmental corticospinal connectivity. Any part of the placode without local function or upstream connections was resected, and the small caudal spinal cord stump closed with pia-to-pia microsutures. The patients were followed for pre- and post-operative neuro-urological status and with serial magnetic resonance imaging (MRI) at 3weeks, 6months, and 2years post-repair. Follow-up period ranged from birth to 3years (mean of 24months). Of the 8 patients analyzed, 7 had a terminal and one a segmental ONTD. Pre-operative neurological level ranged from L4 to S2. Applying our new surgical paradigm, we found no neurological worsening post-operatively. All patients had a neurogenic bladder and bowel dysfunction but none had a high-pressure bladder on urodynamics studies. Early and late MRIs all showed a loose and capacious neural placode to dural sac relationship. None had an inclusion dermoid cyst. We propose a new paradigm for the surgical repair of open neural tube defects with intraoperative neuromonitoring and introduce a safe and reliable technique of placode debulking.

Reducing Neuron Apoptosis in the Pontine Micturition Center by Nerve Root Transfer for Restoration of Micturition Function after Spinal Cord Injury.

Objective The rate of neuronal apoptosis increases after spinal cord injury (SCI). Anastomosing the normal nerve roots above the SCI level to the injured sacral nerve roots can enhance the functional recovery of neurons. Therefore, we evaluated the effect of sacral nerve root transfer after SCI on pontine neuronal survival. Methods Sprague–Dawley rats were randomly divided into three groups: Group A, reconstruction of afferent and efferent nerve pathways of the bladder after SCI; Group B, SCI only; and Group C, control group. We examined pontine neuronal morphology using hematoxylin and eosin (H&E) staining after SCI and nerve transfer. Bcl-2 and Bax protein expression changes in the pontine micturition center were quantified by immunohistochemistry. The number of apoptotic neurons was determined by TUNEL staining. We examined pontine neuronal apoptosis by transmission electron microscopy (TEM) at different time points. Results H&E staining demonstrated that the number of neurons had increased in Group A, but more cells in Group B displayed nuclear pyknosis, with the disappearance of the nucleus. Compared with Group B, Group A had significantly higher Bcl-2 expression, significantly lower Bax expression, and a significantly higher Bcl-2/Bax ratio. The number of apoptotic neurons and neuron bodies in Group A was significantly lower than that in Group B, as indicated by TUNEL staining and TEM. Conclusions These findings demonstrate that lumbosacral nerve transfer can reduce neuronal apoptosis in the pontine micturition center and enhance functional recovery of neurons. This result further suggests that lumbosacral nerve transfer can be used as a new approach for reconstructing bladder function after spinal cord injury.

Utilization of pedicle screw and rod reconstruction system for treating sacral-lumbar defect after excision of sacral chordoma: a case report

Introduction: Sacral chordoma is a malignant lesion that is hard to treat and almost always presents with patient’s significant disability associated with neurological disturbance. The aim of treatment is often to remove the tumor as much as possible while maintaining healthy tissue as many as one’s can. A usage of pedicle-rod system is still debatable for filling the stability after the excision of the sacrum. Methods: We present a case of a 41-year-old patient came with chief complaint of pain on the buttock for quite a long time. On examination, there was a hard-palpable mass on the buttock area which causing pain on palpation. Patient was bedridden due to pain and loss of motoric function. We did a sacral-lumbotomy on this patient, definitely eliminating the whole sacrum and vertebrae L5. Afterwards, we construct the defect by using a pedicle-rod system hoping to maintain the stability. Results: The tumor was successfully removed, together with some sacral nerve plexus and roots of lumbar nerve. After the surgery, the pain improved; however, the patient had defecation and urinal incontinence. Conclusion: Utilization of pedicle screw that may provide stability is much needed. The patient may at least sit up straight after the surgery if the stability is achieved.

001 A Novel Collaboration for Successful Management of Genito-Pelvic Dysesthesias Mediated by Radiculopathy of Sacral Spinal Nerve Roots Within the Cauda Equina: Four-Year Experience

In 2012 Komisaruk reported that women with persistent genital arousal disorder could have a neurologic pathophysiology within the cauda equina. Expanding upon on that concept, we hypothesized that women with broader versions of genito-pelvic dysesthesias (GPD), including unwanted distressing arousal, pain and/or itch, could have their pathophysiology based on sacral spinal nerve roots radiculopathy. To more effectively manage such patients, a robust collaboration among sexual medicine, spine surgery and neurophysiology disciplines was established in 2015.

017 Retrospective Review of Lumbo-Sacral Shockwave Therapy Outcomes for Genito-pelvic Dysesthesia/Persistent Genital Arousal Disorder

The first sexual medicine use of low intensity shockwave therapy (LiSWT) was reported for men with erectile dysfunction (ED) in 2010. Subsequently, LiSWT has been utilized in other sexual medicine conditions as well as other anti-inflammatory painful conditions as arthritis, tendonitis and bursitis. A literature search on Pubmed for LiSWT and pain yields over 1400 citations. Women with genito-pelvic dysesthesia suspected from inflammatory radiculopathy of sacral spinal nerve roots in the cauda equina suffer from unwanted, unrelenting, unprovoked pain, arousal and/or itch symptoms that cause great distress and are highly associated with suicidality. Treatment successes in this population have been limited.

Clinicopathological features and prognosis in patients with presacral recurrent rectal cancer

Objective: To investigate the clinicopathological features and prognostic factors in patients with presacral recurrent rectal cancer (PRRC). Methods: PRRC was defined as recurrence of rectal cancer after radical surgery involving posteriorly the presacral soft tissue, the sacrum/coccyx, and/or sacral nerve root. The diagnosis is confirmed with clinical symptoms (pain of pelvis/back/lower limb, bloody stools, increased frequency of defecation, and abnormal secretions), physical examination of perineal or pelvic masses, radiological findings, colonoscopy with histopathological biopsy, and the evaluation by multi-disciplinary team (MDT). Inclusion criteria: (1) primary rectal cancer undergoing radical surgery without distant metastasis; (2) PRRC was diagnosed; (3) complete inpatient, outpatient and follow-up data. According to the above criteria, clinical data of 72 patients with PRRC in Peking University People's Hospital from January 2008 to December 2017 were retrospectively analyzed. The clinicopathological features and follow-up data were summarized. Cox proportional hazard models was used to analyze the prognostic factors of PRRC. Results: Among 72 patients, 45 were male and 27 were female with a male-to-female ratio of 1.7:1.0. The median age at recurrence was 58 (34 to 83) years and the median interval from surgery to recurrence was 2.0 (0.2 to 17.0) years. The main symptom was pain in 48.6% (35/72) of patients. In addition, gastrointestinal symptoms were found in 25.0% (18/72) of patients. The presacral recurrent sites were presacral fascia in 36 (50.0%) patients, lower sacrum (S3~S5 or coccyx) in 25 (34.7%) patients, and higher sacrum (S1~S2) in 11 (15.3%) patients. Forty-seven (65.3%) patients underwent radical surgery (abdominal resection, abdominoperineal resection, sacrectomy, abdominosacral resection), 12 (16.7%) underwent non-radical surgery (colostomy, cytoreductive surgery), and 13 (18.1%) did not undergo any surgery but only receive palliative chemoradiotherapy and nutritional support treatment. Thirty-three (45.8%) patients received radiotherapy and/or chemotherapy (oxaliplatin, 5-fluorouracil, capecitabine, irinotecan, etc.). All the patients received follow-up, and the median follow-up time was 19 (2 to 72) months. The median overall survival time was 14 (1 to 65) months. The 1- and 3-year overall survival rates were 67.1% and 32.0%, respectively. Univariate analysis showed that age at recurrence (P=0.031) and radical resection (P<0.001) were associated with prognosis. Multivariate analysis demonstrated that radical resection was independent factor of good prognosis (RR=0.140, 95%CI: 0.061-0.322, P<0.001). Conclusions: Patients tend to develop presacral recurrent rectal cancer within 2 years after primary surgery. The main symptom is pain. Patients undergoing radical resection have a relatively good prognosis.

Anterior Sacral Meningocele: A New Classification and Treatment Using the Dorsal Transsacral Approach.

Retrospective case series. Anterior sacral meningocele (ASM) is a rare disorder. We reviewed 11 cases of congenital ASM and classified them into three types based on the anatomy and relationship between the cyst and sacral nerve roots. The cohort with ASM is relatively large; the classification is novel and has not been previously reported. Eleven consecutive patients with ASM who underwent surgery between February 2014 and January 2019 were retrospectively analyzed. They included four males and seven females. The dorsal transsacral approach was adopted in all cases. The follow-up time was at least 3 months. We attempted to classify ASM into three types. Of the 11 cases, six were caudal type, two were paraneural type, and three were nerve-root type. The meningocele was ligated after exploring no nerve involvement, in Type I and II. For Type III, the herniating sac and involved nerve roots were ligated when the nerve roots were indicated as nonfunctional on neurophysiological monitoring; otherwise, the sacral nerve roots were protected and imbricated on the residual sac like a hand-in-glove, and sutured to reconstruct the nerves sleeve. Eight cases were accompanied by tethered cord syndrome (TCS); spinal cord detethering was done with one-stage operation. Ten patients' presenting symptoms improved at 3 to 6 months' follow-up; notably, constipation significantly improved. Only one case accompanied by an epidermoid cyst had a second laparoscopic surgery by a general surgeon. Aim of surgical treatment is to obliterate the communication between the subarachnoid space and herniated sac, detether the spinal cord, and resect the congenital tumor. The new classification helps to recognize the relationship between the meningocele and sacral nerve roots, and subsequently adopt different surgical strategies. We consider the dorsal transsacral approach relatively feasible, safe, and with lower complication. 4.

PD36-10 LUMBO-SACRAL LOW INTENSITY SHOCKWAVE THERAPY FOR GENITO-PELVIC DYSESTHESIA/PERSISTENT GENITAL AROUSAL DISORDER (GPD/PGAD) USING UROGOLD 100 MTS

You have accessJournal of UrologySexual Function/Dysfunction: Female (PD36)1 Apr 2020PD36-10 LUMBO-SACRAL LOW INTENSITY SHOCKWAVE THERAPY FOR GENITO-PELVIC DYSESTHESIA/PERSISTENT GENITAL AROUSAL DISORDER (GPD/PGAD) USING UROGOLD 100 MTS Jessica Yih*, Julea Minton, Catherine Gagnon, Sue Goldstein, and Irwin Goldstein Jessica Yih*Jessica Yih* More articles by this author , Julea MintonJulea Minton More articles by this author , Catherine GagnonCatherine Gagnon More articles by this author , Sue GoldsteinSue Goldstein More articles by this author , and Irwin GoldsteinIrwin Goldstein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000907.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Low intensity shockwave therapy (LiSWT) was introduced to sexual medicine in 2010 as penile shockwave therapy for the non-invasive, non-hormonal, non-pharmacologic treatment of erectile dysfunction. Ever since, sexual medicine clinicians have been broadening LiSWT utilization for bothersome sexual health concerns. LiSWT has been shown to be anti-inflammatory to such processes as radiculitis; researching Pubmed for LiWST treatments of various pain conditions yields over 600 citations. GPD/PGAD is highly associated with despair, emotional lability, catastrophization and suicidality. This study is a retrospective chart review of a highly selected population with distressing GPD/PGAD from suspected radiculitis of sacral spinal nerve roots who were offered lumbo-sacral LiSWT after either minimally invasive spine surgery (MISS) without full resolution of symptoms, were considered to not be a candidate for MISS, or chose not to undergo lumbosacral surgery. METHODS: Patients were selected for treatment who had: 1) distressing symptoms of GPD/PGAD with unrelenting, unprovoked itching, pain or arousal > 6 mo, 2) abnormal neurogenital testing, 3) abnormal lumbo-sacral MRI with degenerative disc disease, herniated nucleus pulposus, annular tear, facet cyst and/or Tarlov cyst; and 4) consultation with a spine surgeon. Treatment involved the UroGold 100 MTS OP155 parabolic probe, Hz 3, energy density 0.06 - 0.10 mJ/mm 2 for 2-4 treatments, with 2100 - 4200 shocks to left and right sacral and lumbar regions. The Patient Global Impression of Improvement (PGI-I) was administered at each office visit starting at the second treatment. RESULTS: Thirteen patients (mean age 38 +/- 11 years) with various symptoms of GPD/PGAD were identified. Seven women had MISS with improvement but not full resolution of their distressing symptoms and 6 did not have spine surgery. Post-treatment, 8/13 (62%) realized improvement of distressing symptoms selecting very much better, much better and somewhat better (PGI-I 1-3). Four patients reported virtual full resolution of GPD/PGAD distressing symptoms with 4-6 months follow-up. The adverse event of temporary worsening of back pain was observed in 5 patients, noted for 1- 14 days post-treatment, that fully resolved. CONCLUSIONS: The initial results of this non-invasive, non-hormonal, non-pharmacologic shockwave energy-based strategy show positive therapeutic benefit for highly selected women with distressing GPD/PGAD secondary to suspected radiculitis of sacral spinal nerve roots. Source of Funding: Not funded. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e726-e727 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Yih* More articles by this author Julea Minton More articles by this author Catherine Gagnon More articles by this author Sue Goldstein More articles by this author Irwin Goldstein More articles by this author Expand All Advertisement PDF downloadLoading ...