Sacral Plexus Nerve Research Articles

Posterior Hip Pericapsular Block (PHPB) with pericapsular nerve group (PENG) block for hip fracture: a case series

BackgroundPain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function.MethodsThis case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded.ResultsThey experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients.ConclusionsUltrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.

The classification of sacral foramina in a South African sample using cadaveric and osteological remains

Sacroiliac (SI) joint fixation is a technique used for SI joint fractures, SI joint dislocations and sacral fractures. Sacral screws can be placed either into the S1 or the S2 vertebrae if S1 is insufficient. Malpositioning of the screws is a common surgical complication as sacral variations exists amongst populations. Complications associated with the misposition of screws can lead to injury of the sacral venous plexus, iliac vessels, or sacral nerve roots. Therefore, this study aimed to evaluate sacral variations in a South African sample by determining distances between the first and second sacral foramina and classifying the common types of sacra found.A quantitative cross-sectional comparative study was conducted. One hundred and twenty (n = 120) dry human sacra and 11 formalin-fixed cadavers were measured to determine the linear distances between the first two anterior and posterior sacral foramina. Additionally, the dry human sacra were classified according to Mahato's classification system. A cadaver SI joint fixation simulation was performed by an orthopaedic surgeon.The mean sacral promontory height was found to be 31.81 mm and 37.52 mm in osteological and cadaver specimens, respectively. The mean anterior pedicle height was significantly different for the left (18.81 mm) and right (21.67 mm) side measurements. A statistically significant difference was found between cadavers and osteological samples for all measurements taken. In the osteological sample, ancestry and age mostly influenced the variations noted.Using Mahato's classification system, sacra with five sacral segments, auricular surfaces extending from the superior part of S1 to the middle of S3 and no accessory L5/S1 articulations had the highest prevalence of 59.17 %.The South African sample exhibited similarities but did not fully compare to other populations. The results in this study should be considered as a reference for surgeries involving the SI joint and sacral foramina. However, where possible, the exact anatomy with possible variations of the patient should be evaluated preoperatively using X-rays and angiograms.

Applied anatomy study and preliminary clinical application of hyper selective neurectomy of triceps branches combined with partial neurotomy of S 2 nerve root to relieve spastic equinus foot

To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S 2 nerve root for relieving spastic equinus foot. Anatomical studies were performed on 12 adult cadaveric specimens. The S 2 nerve root and its branches were exposed through the posterior approach. Located the site where S 2 joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S 2 nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S 2 joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading. The distance between the location where S 2 joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S 2 nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs. HSN of triceps branches combined with partial neurotomy of S 2 nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.

Parasacral ischial plane block for lower limb surgeries: A case series

The para-sacral ischial plane block (PIP block) is a novel fascial plane approach targeting the sacral plexus. This technique simplifies the process as direct visualization of the sacral plexus or sciatic nerve is unnecessary. This retrospective case series includes ten patients with American Society of Anesthesiologists (ASA) physical status II-IV, aged over 18 years, undergoing elective or emergency lower limb surgeries such as debridement and below-knee amputation between May 2023 and November 2023. The block was performed in ≤ 6 minutes for all patients. Onset of subjective analgesia was almost immediate in those presenting with pain. Sensory loss occurred within 9 to 12 minutes. Motor block in the sciatic nerve distribution did not reach Grade 2 in any patient. Hemodynamic stability was notably maintained in all high-risk cases. Intraoperative supplementation with ketamine was required for one patient. The PIP block is a quick, easy-to-perform technique that offers satisfactory surgical conditions and hemodynamic stability in high-risk patients undergoing lower limb surgeries. It also provides prolonged postoperative analgesia and early resumption of oral intake with minimal procedural discomfort.

Efficacy of ultrasound-guided classical versus parasacral parallel shift technique of sacral plexus block for lower limb surgeries - A randomised controlled trial.

Ultrasound-guided sacral plexus block has been used for anaesthesia and analgesia in lower limb surgeries. This study aimed to compare the block performance characteristics after ultrasound-guided (USG) sacral plexus nerve block (SNB) using the parasacral parallel shift (PSPS) approach versus the classical approach in patients undergoing orthopaedic below-knee limb surgeries. In this randomised study, 144 adult patients were randomised to receive USG SNB either by the classical approach (Group C) or the PSPS approach (Group P). A fixed dose of 20 ml of 0.5% ropivacaine was administered. Patients also received USG femoral nerve block with 10 ml of 0.5% ropivacaine. The primary outcome was the scanning time between the two groups. Secondary outcomes were the needling time, sensory and motor block onset and postoperative analgesic characteristics between the two groups. A P value of <0.05 was considered statistically significant. The needling time and the scanning time were significantly lesser in Group P than in Group C (P < 0.05). Complete sensory and motor nerve blockade of the sciatic nerve was significantly higher in Group P (P = 0.029). Block performance time, time for sensory block and time for motor block were significantly less in Group P compared to Group C (P < 0.001). The postoperative analgesic characteristics were comparable between the two groups. The sacral plexus block with ultrasound-guided parasacral parallel shift technique had a lower block performance time with lesser needling and scanning time than the classical approach.

Robotic-assisted versus conventional laparoscopic management of deep endometriosis involving the sacral plexus and sciatic nerve: A comparative before and after study.

To compare robotic-assisted laparoscopy (RAL) and laparoscopy (LPS) for intraoperative and postoperative outcomes, and functional results after a 6-month follow-up period among patients having undergone excision of deep endometriosis (DE) involving the sacral plexus (SP) and sciatic nerve (SN). A retrospective analysis of 100 patients included in our prospective database, who underwent surgical eradication of DE involving the SP and SN at our tertiary referral centre between September 2018 and June 2023. Patients were managed by LPS (n = 71) until 2021, and subsequently by RAL (n = 29). Baseline symptoms and distribution of DE lesions were comparable in the two groups. Nerve dissection, nerve shaving, and intra-nerve dissection were performed in 55 (77.5%), 14 (19.7%), and 2 (5.6%) patients in the LPS group, respectively. Nerve dissection and nerve shaving were performed and in 24 (82.8%) and 5 (17.2%) patients in the RAL group, while no cases of intra-nerve dissection were observed (P = 0.434). Mean operative times were 183.71 ± 85.32 min and 177.41 ± 77.19 min, respectively (P = 0.734). There were no reported cases of conversion to open surgery. Intraoperative and early postoperative complications were comparable between the two groups. At 6 months follow up, we observed a significant reduction in sciatic pain in both the LPS group (39.1% vs 15.6%, P < 0.001) and RAL group (37.5% vs 25%, P = 0.001), with no differences in terms of outcomes (P = 0.1). Both LPS and RAL result in significant long-term relief of symptoms associated with SP and SN endometriosis. Although surgeons found that RAL improved the quality of excision of these specific DE localizations, our study did not reveal significant advantages in terms of its outcomes.

Ultrasound-guided sacral plexus and sacral nerve root blocks alleviating neuropathic pain caused by sacral plexus injury: a case presentation.

Ultrasound-guided sacral plexus and sacral nerve root blocks alleviating neuropathic pain caused by sacral plexus injury: a case presentation.

Laparoscopic Nerve Detrapment and Neurolysis of Somatic Pelvic Nerves in Deep Endometriosis: Prospective Study of 433 Patients

<h3>Study Objective</h3> To review efficacy and feasibility of laparoscopic decompression and neurolysis for cases of endometriosis involving sacral plexus and/or somatic nerves causing somatic compression and ano-genital pain on a large case series. <h3>Design</h3> Prospective case-series, single-centre, single-surgeon study on 433 patients. In a 7-year period. <h3>Setting</h3> Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona - Italy; 7-years period <h3>Patients or Participants</h3> 433 patients with deep infiltrating endometriosis complaining of recurrent sciatica and ano-genital pain in addition to "usual" endometriosis symptoms <h3>Interventions</h3> (A) medial approach for deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerve; (B) lateral approach for isolated endometriosis of pelvic wall and somatic nerves. All the procedures were performed by a gynecologic pelvic surgeon skilled in neuro-anatomy (M.C.) <h3>Measurements and Main Results</h3> All the treated patients showed laparoscopic and pathology report evidence of compression above the somatic nervous structures, requiring decompression, whereas in 145 (33,5%) patients, there was clear infiltration of those structures, deepening to the perineural and axonal planes. Complete relief from neurologic symptoms was achieved in all patients at 6 months after surgery, post-operative neuritis was reported in 62 patients (14.3%). <h3>Conclusion</h3> Pelvic wall spread of deep infiltrating endometriosis might be more usual than thought. Laparoscopic retroperitoneal nerve-sparing approach to endometriosis extending to the pelvic wall with somatic nerve compression proved to be a feasible and safe procedure, effective in pain relief, recovery of impaired neurological functions and neuromotoric impairment motoric symptoms of the pelvis and the leg related to endometriosis. It should be limited to referral laparoscopic centres lead by surgical neuro-anatomy skilled surgeons.

Natural Orifice Specimen Extraction Colorectal Resection for Deep Endometriosis: A 50 Case Series

To describe our experience with the use of natural orifice specimen extraction (NOSE) technique for segmental bowel resection in patients with colorectal endometriosis. A retrospective, observational study. A single tertiary referral center. A total of 50 consecutive patients undergoing NOSE colectomy for colorectal endometriosis in our center, between March 2021 and November 2021. NOSE colectomy for colorectal endometriosis with removal of the excised colorectal specimen through the vagina or the anus. A total of 45 procedures were performed laparoscopically and 5 procedures were performed robotically. All interventions were performed by 3 endometriosis surgeons in a multidisciplinary fashion, with involvement of a colorectal surgeon. There were no cases of conversion to laparotomy. Concomitant surgical procedures were performed in all cases. Eleven patients had concomitant interventions on the digestive tract. Five patients had concomitant interventions on the sacral plexus or sciatic nerve. All anastomoses were lateroterminal. The mean height of colorectal anastomosis was 12 cm (standard deviation [SD] ± 4), and the mean length of the excised colorectal specimen was 9 cm (SD ± 4). In 29 cases, the specimen was extracted through the vagina and in 21 cases through the anus. A total of 5 patients required a reoperation in the early postoperative period: We identified 1 case of anastomotic leak, 1 case of postoperative bowel obstruction, 1 case of hemorrhage and 2 cases of pelvic collection (no macroscopic evidence of pus). No patient received blood transfusion. The mean operative time was 158 minutes (SD ± 70) and mean hospital stay was 4 days (SD ± 1). NOSE colectomy is a reproducible surgical technique for the management of colorectal endometriosis. The complication rate appears comparable with the conventional (minilaparotomy) surgical approach. In experienced hands, this technique has a short learning curve, both in laparoscopy and in robotic surgery.

Excision of a Deeply Infiltrating Endometriosis Nodule and Neuroma Involving the Sacral Nerve Root Plexus Adjacent to the Ischial Spine

Study Objective Present a surgical video that demonstrates the use of anatomic landmarks and dissection techniques for the laparoscopic excision of deeply infiltrative endometriosis at the ischial spine. This video will highlight the anatomy relevant to performing a nerve sparing technique to minimize neurological sequelae when excising nodules adjacent to the sacral nerve plexus and inferior hypogastric nerve. Design Surgical Educational Video. Setting Tertiary Referral Center at an Academic Residency Program. Patients or Participants 30-yo G0P0 with cyclical dysmenorrhea, gluteal pain, & dyspareunia that presented with a 2cm deeply infiltrative endometriotic nodule at the level of the ischial spine. Interventions Laparoscopic excision of deeply infiltrative endometriotic nodule at the ischial spine utilizing a nerve sparing technique. Measurements and Main Results 3.5 × 1.7 × 1.8 cm endometriotic nodule was confirmed by pathology. Immunohistochemical findings of +CD-10 which is consistent with stroma surrounding endometriosis and +S-100 consistent with neuroma. Operative time 145 minutes. EBL 25mL. Conclusion Surgical excision of Deeply Infiltrative Endometriotic lesions at the level of the ischial spine present unique challenges. By employing knowledge of the anatomy of the sacral nerve root plexus in relation to the ischial spine, inferior hypogastric plexus, inferior hypogastric plexus, and avascular planes, safe nerve sparing excision can be accomplished. Present a surgical video that demonstrates the use of anatomic landmarks and dissection techniques for the laparoscopic excision of deeply infiltrative endometriosis at the ischial spine. This video will highlight the anatomy relevant to performing a nerve sparing technique to minimize neurological sequelae when excising nodules adjacent to the sacral nerve plexus and inferior hypogastric nerve. Surgical Educational Video. Tertiary Referral Center at an Academic Residency Program. 30-yo G0P0 with cyclical dysmenorrhea, gluteal pain, & dyspareunia that presented with a 2cm deeply infiltrative endometriotic nodule at the level of the ischial spine. Laparoscopic excision of deeply infiltrative endometriotic nodule at the ischial spine utilizing a nerve sparing technique. 3.5 × 1.7 × 1.8 cm endometriotic nodule was confirmed by pathology. Immunohistochemical findings of +CD-10 which is consistent with stroma surrounding endometriosis and +S-100 consistent with neuroma. Operative time 145 minutes. EBL 25mL. Surgical excision of Deeply Infiltrative Endometriotic lesions at the level of the ischial spine present unique challenges. By employing knowledge of the anatomy of the sacral nerve root plexus in relation to the ischial spine, inferior hypogastric plexus, inferior hypogastric plexus, and avascular planes, safe nerve sparing excision can be accomplished.

The Importance of Sacral Neuroanatomy in Pain Syndromes and Procedures

: The neural plexus exists in different parts of the body. The sacral plexus is the lowest neural network in the body that is responsible for sensory and motor innervation to a large part of the body. The sacral plexus or sacral nerve roots may be damaged by diseases, such as disc herniation, spinal canal stenosis, and cancer or iatrogenic injuries during surgery or interventional pain procedures (open spinal surgeries, hip surgeries, percutaneous endoscopic disc decompression, trans-sacral epiduroscopic laser decompression, …). Patients with sacral nerve damage may experience a variety of symptoms, including low back pain radiating to the legs, sensory disturbance in the buttocks or legs, motor weakness in the legs, bladder or bowel dysfunction (urinary retention/incontinence, defecation’s problems), or sexual dysfunction. Therefore, complete familiarity with the anatomy of the sacral plexus is very important. In this article, we tried to review the anatomy of the sacral plexus and sensory or motor innervations of each terminal branch of the sacral plexus. Also, the clinical importance of these nerves in the development of pain syndromes and diagnostic and therapeutic methods for damage to the terminal branches of the sacral plexus were investigated.

Clinical application of enlarging greater ischiatic notch by ilium osteotomy to expose the sacral plexus via the gluteal approach

Objectives: To observe the possibility of enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus,and performing the nerve graft for surgical repairing the sacral plexus ruptured injuries or sacral plexus nerve tumor resection. Methods: The clinical data of 10 patients with sacral plexus injury or sacral plexus nerve tumor underwent the surgical operation via the expanded greater sciatic notch at Department of Hand Surgery,Beijing Jishuitan Hospital from July 2016 to November 2020 were retrospectively analyzed.There were 4 male and 6 female patients,with an age of (38.0±9.3)years (range:26 to 56 years).There were 8 cases with sacral plexus injury at the intrapelvic or covergence level (deep to the piriformis). Out of this 8 cases,4 cases with intrapelvic pan-sacral plexus injury,1 case with upper sacral plexus injury and 3 cases with convergence level pan sacral plexus injury.Another 2 cases were sacral plexus neoplasm.The average time from injury or onset to operation was 10.4 months (range:1.5 to 60.0 months). All cases were performed surgery for reaching the intrapelvic upper sacral plexus as well as the covergence level of sacral plexus with enlarging the greater sciatic notch by illium osteotomy through the posterior gluteal approach.Intraoperation the sacral plexus ruptured injurie was repaired and the sacral plexus nerve tumor was resected.Intraoperative findings,postoperative complications and healing of patients were recorded. Results: All the 10 patients underwent the sacral plexus surgical exploration and cutaneous nerve graft for sacral plexus nerve repairing or neurolysis or neoplasm resection through the posterior gluteal approach successfully.The length and width of illium osteotomy mass were (2.9±0.4)cm (range:2.5 to 3.8 cm) and (2.5±0.5)cm (range:1.5 to 3.4 cm) respectively.The median intraoperative bleeding volume was (M(QR))800(800)ml (range:400 to 2 000 ml).There were no complication with major vascular injury and hematoma formation,and all incisions healed.The postoperative follow-up was 29.8 months (range:1.5 to 54.0 months).Nine cases of iliac osteotomy were healed,and 1 case was not healed because the follow-up was only 1.5 months. Conclusions: The intrapelvic upper sacral plexus and the convergence level of sacral plexus deep to the piriformis can be exposed clearly through this posterior gluteal approach via illium osteotomy for enlarging the greater sciatic notch,and there was enough operative space that surgical exploration and nerve graft or nerve transfer or neoplasm resection can be performed.

Postoperative Outcomes after Surgery for Deep Endometriosis of the Sacral Plexus and Sciatic Nerve: A 52-patient Consecutive Series

To assess 1-year postoperative outcomes of surgery for deep endometriosis involving the sacral roots and sciatic nerve. Retrospective case series. Three referral centers. Fifty-two women. Surgery for deep endometriosis involving the sacral roots and sciatic nerve. Deep endometriosis involved the sacral roots in 49 women (94.2%) and the sciatic nerve in 3 cases (5.8%). Sciatic pain (buttock or leg) was recorded in 43 women (82.7%), pudendal neuralgia in 11 women (21.2%), and leg motor weakness in 14 cases (27%). The surgical procedures carried out on the pelvic nerves included complete release and decompression (92.3%), excision of the epineurium by shaving (5.8%), and intraneural excision (1.9%). Additional major surgical procedures involved the digestive tract in 82.7% of the cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of the cases. Self-catheterization was required in 14 cases (27%) at 3 weeks after surgery and in 3 women (5.8%) 12 months later. One-year follow-up showed significant improvement in quality of life measured using the Short-Form 36 questionnaire and standardized gastrointestinal scores. De novo hypoesthesia, hyperesthesia, or allodynia were recorded in 9 women (17.2%). The cumulative pregnancy rate was 77.2%% after natural conception in 47%. Laparoscopic management of deep endometriosis involving the sacral roots and sciatic nerve improves patients' symptoms and overall quality of life. Although pain reduction may be rapid after surgery, other sensory or motor complaints, including bladder dysfunction, may be recorded over months or years.

Adenot. — Traumatic Paralysis by Compression of the Sacral plexus during Labor. (Americ. Journ. Of Obstetries etc., 1894, I / V, p. 570; Nouv. Arch. D'Obst. Et de Gyn., 1893, XI). Traumatic paralysis due to compression of the sacral nerve plexus during childbirth

This form of paralysis occurs even more often with hemiplegia, paraplegia, and personal paralysis due to kidney damage, depending on pregnancy. Some of them deny such an origin of paralysis (Churchill); others, without denying their existence, attribute the paralysis not to the pressure of the head, but to the forceps. The erroneousness of the last opinion is proved by the case of Bianchi, in which a woman in labor complained of an onset of her legs 4 hours before the imposition of forceps. Burns and Jaccoud observed similar paralysis and post-normal childbirth.

Putative Clinical Implications of Unilateral Ossified Sacrospinous Ligament

Abstract Introduction Sacrospinous ligament (SSL) is a thin structure that extends from the ischial spine to the lateral margins of sacrum and coccyx, anterior to the Sacrotuberous ligament (STL). The internal pudendal and inferior gluteal vessels, pudendal nerve, sciatic nerve, and other branches of sacral nerve plexus pass through the greater sciatic foramen (GSF) in close proximity to the ischial spine and SSL. Objective This study aimed to report a case encountered during the routine osteology tutorial, where one of the pelvises presented with ossified SSL on the right side along with ossification of lumbosacral and the sacroiliac joints. Case Report The SSL of the right side of the pelvis was completely ossified, extending between the ischial spine and fifth piece of sacrum. The ossification had a broad-based origin from the sacrum and tapered as in proceeded to the ischial spine. It was attached to the ischial spine with a slight enlargement. Moreover, the lumbosacral and the sacroiliac joints also appeared to be ossified. Conclusion Ossification of the SSL can restrict the lesser sciatic foramen and the greater sciatic foramen, thus causing compression of neurovascular structures traversing these areas. This can be the causative factor in pudendal nerve/sciatic nerve entrapment and can be a cause for undiagnosed chronic perineal pain. Proper anatomical knowledge and radiologic studies can be utilized for accurate diagnosis and treatment of neurovascular compression syndromes and also during reconstructive procedures of the pelvic floor and treatment of uterovaginal prolapse.

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.

Analysis of anatomical variations of intrapelvic vessels for advanced pelvic surgery

BackgroundIn pelvic surgery, it is important to anticipate potential anatomic variations, which may be unknown, and inter-relationships among intrapelvic vessels. Here, we comprehensively analyzed intrapelvic vessel patterns.MethodThis retrospective analysis included 81 patients that underwent colorectal surgery in our institution in 2016. A total of 162 half-pelvises were imaged with contrast-enhanced computed tomography. We scrutinized thin-slice images.ResultsWe found variations in the number of internal iliac veins. In 47.5% of cases, one internal iliac vein drained into the ipsilateral common iliac vein in both halves of the pelvis. In the other cases, several internal iliac veins were observed in one or both halves of the pelvis. We analyzed the inter-relationships between the superior gluteal artery and the sacral nerve plexus in pelvic halves. Superior gluteal arteries ran between the 5th lumbar nerve and 1st sacral nerves, in 82% of halves, and lateral to the 5th lumbar nerve, in 17% of halves. Dorsally, the superior gluteal artery ran on the medial side of the internal iliac vein in 15% of halves. In 28% of half-pelvises, two superior gluteal veins were observed. Superior gluteal veins passed through the sacral nerve plexus lateral to 5th lumbar, between 5th lumbar and 1st sacral, and between 1st and 2nd sacral nerve, in 42.0, 47.5, and 37.7% of halves, respectively. We evaluated the rate of symmetric pelvic anatomies, and found that all anatomic variations formed symmetrically, except the number of internal iliac veins.ConclusionThis study clarified the anatomical variations of intrapelvic vessels and their inter-relationships. These findings will benefit our understanding of pelvic anatomy and enhance the safety of radical surgery for treating pelvic diseases.

Laparoscopic Neurolysis for Deep Endometriosis with Somatic Nerves Involvement: A Prospective Cohort Study on 402 Patients Treated in a Third-Level Referral Center

Study Objective To review efficacy and feasibility of laparoscopic decompression and neurolysis for endometriosis involving sacral plexus and/or somatic nerves on a large case series. Design Prospective case-series, single-centre, single-surgeon study on 402 patients. Setting Department of Obstetrics and Gynecology, IRCCS Sacro Cuore Don Calabria Hospital, Verona - Italy. Patients or Participants In a 9-year period, 402 consecutive patients with deep infiltrating endometriosis (DIE) complaining of recurrent sciatica and ano-genital pain were treated by laparoscopic decompression or neurolysis of sacral roots and somatic nerves. The median follow up was 44,7 months. Interventions All the procedures were performed by a gynecologic pelvic surgeon skilled in neuro-anatomy (M.C.) Decompression and neurolysis of the involved neural structures was achieved by means of a tranperitoneal medial approach, by means of a lateral approach from the ileolumbar space, or with both the approaches in a combined technique. Nerve-sparing radical excision of DIE was performed laparoscopically in all cases. Measurements and Main Results In all of the 402 patients a laparoscopic evidence of nervous compression of somatic structures and infiltration of their fascial envelope was shown, whereas in 89 patients (22.1%) the same structures were deeply infiltrated, towards the assonal and peri-nevral planes. In all of the patients a surgical whole decompression and partial neurolysis of nervous structures was performed, where in 89 (22.1 %) cases a complete neurolysis was required. Complete relief from neurologic symptoms was achieved in all patients at 6 month after surgery, whereas post-operative neuritis was reported in 78 patients (19.4%) and successfully treated with steroids or/and anti-epileptic and opioids drugs. Conclusion Laparoscopic retroperitoneal nerve-sparing approach to endometriosis extending to the pelvic wall with somatic nerve compression proved to be a feasible and safe procedure, effective in pain relief, recovery of impaired neurological functions and neuromotoric impairment symptoms of the pelvis and the leg.

502 Translumbosacral Anorectal Magnetic Stimulation (TAMS): Novel Anorectal Neurophysiology Test, Normative Values, and Effects of Gender

INTRODUCTION: Although anal electromyography and pudental nerve latency have been used for assessment of anal neuropathy, neither test is used routinely in clinical practice, because of significant deficiencies with each test and were not endorsed by AGA. Also neither test comprehensively assesses the entire nerves from their origin in spinal cord to anal innervation. Truslumbosacral Anorectal Magnetic Stimulation (TAMS) is a novel, non-invasive test for identifying anorectal neuropathy. It evaluates the neuronal integrity of lumbar and sacral plexus nerves from their origin in spinal cord to their innervation in the rectum and anus by measuring the latencies of motor evoked potentials (MEPs). Our aim was to determine the normal values for TAMS in healthy subjects and evaluate the effects of gender. METHODS: Healthy subjects underwent bilateral translumbar and transacral magnetic stimulation using a 90 mm magnetic coil (Magstim, UK). Motor evoked potentials (MEPs) were recorded simultaneously from the rectum and anus using two pairs of bipolar ring electrodes. The 8 MEP latencies from each healthy subject were measured (mean ± SEM) and gender differences compared. RESULTS: Forth-eight healthy subjects (18-59) years, F/M = 32/16) were evaluated. The mean latency of all 8 MEPs, and in men and women are summarized in Table 1. Although there are small differences in MEP latencies between individual sites, overall there were no differences between the lumbar and sacral nerve latencies or between the right or left side or between the anal and rectal sites (Table 1). Also there were no differences in MEP latencies between men and women for any of the 8 sites. Age is not significantly associated with the anal or rectal MEP latencies (r = 0.09 to 0.326), except weak association for right sacro-rectal MEP (r = 0.386), P = 0.009). CONCLUSION: This study provides normative values for the bilateral lumbar and sacral-anorectal MEPs in healthy subjects. Neither gender nor age appear to influence the rectal and anal MEP latencies. These data will provide the basis for comparing the novel TAMS test findings in patients with those from suspected anorectal or pelvic neuropathy.

Intravesical electromotive administration of botulinum toxin type A in improving the bladder and bowel functions: Evidence for novel mechanism of action

Objective: To examine the hypothesis that what is the concomitant mechanism of action botulinum toxin type A (BoNTA) administration by intravesical electromotive into the bladder resulting in bladder function improvement. We also tried to confirm the possibility of retrograde trans-axonal transportation of toxin. Design: Animal study. Setting: Ten male rabbits were divided into two groups. Participants: Group 1 (G1) (n = 5) (BoNTA/EMDA), and group 2 (G2) (n = 5) the control group. Interventions: Animals in G1received 10 IU/Kg of intravesical BoNTA through a specific catheter for electromotive drug administration (BoNTA/EMDA). About 0.1–0.15 ml of toxin was diluted in 1 ml of distilled water. The maximum frequency of the device for drug solution delivery was set at 4 mA for 15 min. In G2 as the control group, the same procedure was performed to deliver normal saline to the bladder. Outcome measures: Multiple biopsies were taken from bladder’s contiguous structures one month postoperatively. The immunohistochemical (IHC) evaluation was performed with anti-clostridium botulinum toxoid type A mouse IgM monoclonal antibody. Results: In specimens of G1, BoNTA penetrated through muscular layers of the bladder wall and the staining was uniform in the urothelium, interstitium, and muscular layers. Positive IHC staining showed that BoNTA was traced in the upper and lower spinal cord in addition to pelvic nerve, sacral nerve plexus, intestine wall, and pelvic floor muscle. In G2, all the specimens were intact in IHC staining. Conclusions: The presence of BoNTA in lower and upper spinal cord suggests the possibility of retrograde trans-axonal transfer of toxin to lower and upper neural pathways which may result in simultaneous improvement in bladder and bowel functions.