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PubMed1981

[A case of sacral neurinoma].

A case of sacral neurinoma diagnosed in a 67-year-old woman whose clinical symptomatology consisted for fully 54 years of faint but persistent episodes of lumbo- and sacralgia is reported. Only at the terminal moment of observation did the patient present motor and sensitivity disturbances in the lower extremities, paralysis of the sphincters and sacral decubitus. The mass was identified radiologically and submitted to biopsy. It was localized in the left wing of the sacrum and on the corresponding side of the iliac bone, and presented a diameter of 6 X 9 cm. The slow, practically asymptomatic course, the exclusively intra-osseous site, the histological report and late onset of a cauda syndrome, suggest that the origin of the neoplasia lies in the sacral nerves.

Aged↗

PubMed1982

[CT findings in ileo-caval thrombosis (author's transl)].

Thrombosis of a large vein can be demonstrated by CT. The thrombosed vein has a hypodense lumen, with a somewhat increased diameter which does not opacify after intravenous contrast injection, but which shows a narrow hyperdense margin. Collateral vessels in the pelvic or paravertebral plexus and dilated veins in the abdominal skin are indirect evidence of ileo-caval thrombosis. CT can also demonstrate the cranial extent of a caval thrombosis. Venous thrombosis demonstrated by CT is an important additional finding in the pre-operative examination of the abdomen.

Adolescent↗

PubMed1985

Cystic intra-abdominal testicular torsion in an infant.

We report on a 3-month-old infant with cystic intra-abdominal testicular torsion. He presented with abdominal distension and pain. Physical examination showed a movable, well delineated mass in the right iliac and lumbar fossae. Exploration revealed that the mass was connected to the abdominal aorta by a thin vascular cord that was twisted before reaching the mass. The histological study showed that the mass corresponded to a testis with cystic formations. The testicular parenchyma was necrotized, although isolated seminiferous tubules were found. The cystic cavities were filled by hematic and necrotic material, and exhibited no epithelial lining. A fibrous layer in continuity with interstitial hemorrhage surrounded the cysts. The twisted vascular cord corresponded to a spermatic cord with dilated pampiniform plexus veins. The differential diagnosis and the etiopathogenesis of the lesion are discussed.

Abdomen↗

PubMed1979

Distal spleno-renal shunt for portal decompression in childhood.

Successful portal decompression presents a unique challenge in children. The meso-caval shunt, utilizing the large caliber iliac vein in constructing the anastomosis, has been accepted as the standard operative procedure for treating these patients. Technical and anatomic difficulties, however, often prevent the successful performance of this shunt. The proximal spleno-renal shunt, advocated by many as an alternative in children, incurs the penalty of splenectomy. Furthermore, in both techniques, portal venous blood is preferentially shunted from the liver, posing a potential for subsequent development of hepatic encephalopathy as the patients mature. The distal spleno-renal shunt avoids these problems by selectively decompressing the esophageal venous plexus through the spleen. With this procedure, the majority of portal venous blood flow is maintained and the spleen is preserved. The present report describes three children in whom the distal spleno-renal shunt has been successfully employed for portal decompression. The youngest of these patients was 2 1/2 yr of age at the time of operation and has a patent portal-systemic shunt 18 mo postoperatively. This experience confirms the effectiveness of the distal spleno-renal shunt as an alternative to the meso-caval shunt, especially in children with inflammatory involvement of the superior mesenteric vein.

Child↗

PubMed2001

[Multiple spinal arteriovenous fistulas occurring at conus medullaris and dura of the sacral region: a case report].

Multiple arteriovenous fistulas (AVFs) of the spine are rare. The authors reported a case of spinal AVFs occurring at two separate sites including the conus medullaris and the dura of the sacral region. A 31-year-old man had a two-week history of progressive low back pain, mild gait disturbance and dysuria. Examination revealed mild motor weakness of both legs, disturbance of superficial sensibility below the L4 dermatome on both sides and dysuria. Sensory disturbance was most obvious in the perianal region, although deep sensibility was not disturbed. Magnetic resonance images (MRIs) of the spine showed many serpentine flow void signals from the lower thoracic region to the sacral region, and spinal arteriovenous malformations were suspected. Selective spinal angiography revealed two AVFs at the separate sites including intradural perimedullary AVF at the conus medullaris and dural AVF at the sacral region. The dural AVF of the sacral region was fed by the left lateral sacral artery and drained through the dilated coronal venous plexus to Th11 level. Embolization with N-butylcyanoacrylate (NBCA) was performed using an endovascular procedure for both AVFs. Although recanalization of the dural AVF of the sacral region was confirmed by angiography two weeks later, it was treated successfully by the surgical approach.

Adult↗

PubMed1986

Anatomic study of the lateral cutaneous rami of the subcostal and iliohypogastric nerves.

On the supposition that some "pseudocoxalgias" might be due to a neuralgia of the lateral rami leaving the subcostal and iliohypogastric nerves above the lateral edge of the iliac crest, the authors undertook an anatomic study of their pathways and pattern of distribution. These rami supplying the skin below the iliac crest, which they cross close together, the ramus arising from the subcostal nerve by perforating the internal and external oblique abdominal muscles, that arising from the iliohypogastric nerve a little lower, creating a bony groove palpable in thin subjects and transformed into an osseomembranous tunnel by the aponeurosis of these muscles. This arrangement may give rise to an entrapment syndrome. At this intersection, the course is either vertical or "bayonet-shaped", directly subcutaneous, and hence exposed to possible friction and microtraumata (tight clothes). The two rami are of unequal length. Frequently, the ramus arising from the subcostal nerve is short, not exceeding 10 cm, below the iliac crest, thus corresponding to the usual description. That arising from the iliohypogastric nerve descends further, passing 3 to 5 cm anterior to the great trochanter. It ends either at this level or 8 to 10 cm below. This accounts for the distribution of the pain felt when there is irritation of this ramus.

Female↗

PubMed2002

Coexistence of a pectoralis quartus muscle and an unusual axillary arch: case report and review.

A pectoralis quartus muscle and an unusual axillary arch were found on the left side of a female cadaver. The axillary arch was a musculoaponeurotic complex continuous with the iliacal fibers of the latissimus dorsi. The muscular part, together with the tendon of pectoralis major, inserted into the lateral lip of the bicipital groove of the humerus, whereas the aponeurotic part was formed by a fibrous band that extended deep to the pectoralis major to insert into the coracoid process between the attachments of the coracobrachialis and pectoralis minor. The pectoralis quartus originated from the rectus sheath, and joined the inferior medial border of the fibrous band of the axillary arch, at the lateral edge of the pectoralis major. The axillary arch muscle crossed anteriorly the axillary vessels and the brachial plexus. The clinical importance of these muscles is reviewed.

Aged↗

PubMedDate not supplied

[Lumbar plexopathy secondary to pelvic hydatid cyst].

INTRODUCTION: Hydatidosis is a zoonosis caused by larvae of the hydatid tapeworm Echinococcus granulosus, which usually affects the liver, lung, myocardium, brain and bones. On rare occasions hydatid cysts give rise to peripheral neurological manifestations. CASE REPORT: Male, aged 72, who had received a pacemaker as a consequence of a complete auriculoventricular block. During implantation, one hepatic and two pelvic hydatid cysts were discovered. Consulted doctor about right inguinal pain, which irradiated to the lumbar region and along the inner and posterior sides of the thigh, down to the ankle. Exploration revealed a lump in the right iliac fossa and in the lower right limb, hypaesthesia in the anterior side of the thigh, paresis on bending the hip and on extension of the knee, and patellar areflexia. Computerised axial tomography revealed growth of the pelvic cysts and compression of the gluteal veins. Electromyographic exploration of the right quadriceps showed denervation and reinnervation activity. CONCLUSION: Of all cases of abdominal hydatidosis, 6.7% presented extra hepatic affectation and only 0.7% were seen to have pelvic hydatid cysts. These usually give rise to disorders due to local compression of the genital organs, the urinary tracts, and vascular and bony structures. Lesions in the lumbosacral plexus, however, have only been reported on very few occasions

Aged↗

PubMed2003

[Applied anatomy of the path of retroperitoneal laparoscopy surgery].

OBJECTIVE: To discover the anatomical basis of retroperitoneal laparoscopic surgery. METHODS: Twenty Chinese adult cadavers including 12 and 8 woman were anatomized. The relationship between nerves, vessels of the lateral abdominal wall, retroperitoneal structures and the path of retroperitoneal laparoscopic surgery were measured. RESULTS: In male cadavers, the distance between the iliac crest and lumbar trigonum was 4.02 +/- 1.26 cm on the left, and 3.83 +/- 0.90 cm an the right. The distance between the iliac crest and ilio-hypogastric nerve was 0.82 +/- 0.13 cm on the left and 0.84 +/- 0.08 cm on the right. The distance between the subcostal nerve and XII rib in the posterior axillary line and midaxilla line was 0.79 +/- 0.26 cm, 1.65 +/- 1.12 cm on the left and 0.78 +/- 0.30 cm, 1.59 +/- 1.07 cm on the right respectively. The distance between the ureter of inferior pole of kidney and extra-border of psoas was 2.24 +/- 0.67 cm on the left and 2.19 +/- 0.73 cm on the right. The distance between crossing of the ureter and iliac vessels and extra-border of psoas was 3.91 +/- 0.59 cm on the left and 3.76 +/- 0.53 cm on the right. In female cadavers, the distance between the iliac crest and trigonum lumbale was 3.90 +/- 0.37 cm on the left and 3.87 +/- 0.37 cm on the right. The distance between the iliac crest and ilio-hypogastric nerve was 0.94 +/- 0.06 cm on the left and 0.93 +/- 0.10 cm on the right. The distance between the subcostal nerve and XII rib in the posterior axillary line and midaxilla line was 0.61 +/- 0.14 cm and 1.37 +/- 0.89 cm on the left and 0.64 +/- 0.13 cm, 1.32 +/- 0.95 cm on the right respectively. The distance between the ureter of inferior pole of kidney and extra-border of psoas was 2.00 +/- 0.23 cm on the left and 1.91 +/- 0.13 cm on the right. The distance between crossing of the ureter and iliac vessels and extra-border of psoas was 3.43 +/- 0.31 cm on the left and 3.85 +/- 0.43 cm on the right. CONCLUSIONS: The top of the lumbar trigonum which is 2 cm above the iliac crest selected as the first point and 2 cm inferior to the XII rib in the posterior axillary line selected as the second point is the anatomical basis for retroperitoneal laparoscopic surgery. It can reduce the opportunity to injury nerves, vessels and retroperitoneal structures while making retroperitoneal laparoscopic surgery easy.

Abdominal Wall↗

PubMed1996

[Damage to the inguino-femoral nerves in the treatment of hernias. An anatomical hazard of traditional and laparoscopic techniques].

Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.

Femoral Nerve↗

PubMed1996

[L5-S1 herniated disk migrated to the anterior part of the right sacral wing with compression of the right lumbosacral roots].

PURPOSE OF THE STUDY: The goal of this study was to report an exceptional case of far lateral and anterior disc herniation at L5-S1 level. CASE REPORT: A 47 year-old man presented a right L5 radicular pain with motor deficit of tibialis anterior and extensor hallucis longus resisting to medical management. Standard X-rays showed a degenerative process of L5-S1 disc. The CT scan was at first considered as normal. The myelogram was normal. A second study of the CT scan showed an opacity next to the L5 right root in front of the sacral wing. A discography combined with CT scan was then performed showing the migrated herniated disc from L5-S1 to the anterior part of the right sacral wing in contact with L5 root. RESULTS: Surgery was performed by transperitoneal approach and needed a difficult dissection of hypogastric vessels. The herniated disc was found behind the L5 root. A L5-S1 disc excision and arthrodesis with iliac grafts were performed. The result has been very good with relief of the pain and recovery of the palsy within a month. CONCLUSION: The lecture of a CT scan should include the far extraforaminal zone if there is no compression in the spinal canal. Such an anterior migration of an herniated disc has not been already described as far as we know.

Diskectomy↗

PubMedDate not supplied

[Structural and functional anatomical bases of deep venous insufficiency of the lower limbs].

The authors consider the Extent of the several anatomical structures which constitute the deep venous network, and the part they can take in the case of deep venous insufficiency. Congenital Vascular diseases are called back in mind when considering Embryology, and point out the extent of the deep venous state; such veins can gather in periarterial plexus, at the muscular Level, and in going past all along main arterial axes. Among all the critical points of these axes, we must keep the popliteal veins, the femoral crossing, and the iliocaval one and elsewhere, the important question of venous valves and communicating and perforating veins. The part of the lymphatic network must be pointed out, because of its extent in the stasis phenomenons.

Femoral Vein↗

PubMed2005

Lateral femoral cutaneous nerve: an anatomic study.

The purpose of our study was to determine the location of the lateral femoral cutaneous nerve and its branches at the inguinal ligament and proximal thigh. We think that further defining the location of the nerve and its branches based on certain measurements from known anatomic landmarks would enable us to determine a danger zone that could aid in preventing iatrogenic injury to the lateral femoral cutaneous nerve. The anatomic course of the lateral femoral cutaneous nerve was studied in 29 cadaver specimens and distances from various landmarks were recorded. In addition, the branching pattern of the nerves was recorded. We observed variability in the course and branching patterns of the lateral femoral cutaneous nerve. The lateral femoral cutaneous nerve was found to potentially be at risk as far as 7.3 cm medial to the anterior superior iliac spine along the inguinal ligament and as much as 11.3 cm distal on the sartorius muscle from the anterior superior iliac spine. As many as five branches of the lateral femoral cutaneous nerve were found and in 27.6% of cases the lateral femoral cutaneous nerve branched before traversing the inguinal ligament. We used this information to describe a danger zone, which could be used as a guide to help prevent unnecessary injury during certain procedures.

Adult↗

PubMed1997

The efficacy and complications of laparoscopic presacral neurectomy in pelvic pain.

OBJECTIVE: To evaluate the efficacy and complications of laparoscopic presacral neurectomy in pelvic pain. METHODS: We reviewed records of 655 patients receiving laparoscopic conservative surgery and laparoscopic presacral neurectomy for diagnoses including adenomyosis with dysmenorrhea (n = 55), moderate and severe endometriosis with dysmenorrhea (n = 127), minimal and mild endometriosis with dysmenorrhea (n = 208), primary dysmenorrhea (n = 99), and chronic pelvic pain with or without pathologic disease (n = 166). Pain relief was evaluated at least 12 months postoperatively. RESULTS: Pain relief was evaluated in 527 patients. Significant pain relief (no pain or mild pain requiring no medication) was found in 22 (52%) of 42 women with adenomyosis, in 75 (73%) of 103 with moderate to severe endometriosis with dysmenorrhea, in 123 (75%) of 164 with minimal to mild endometriosis with dysmenorrhea, in 64 (77%) of 83 with primary dysmenorrhea, and in 84 (62%) of 135 with chronic pelvic pain. There were four major complications (0.6%) that required further surgery, including injury of the right internal iliac artery (n = 1) and chylous ascites (n = 3). Three cases (0.5%) had laceration of the middle sacral vein controlled during laparoscopy. In addition, 485 (74%) of the 655 patients complained of constipation after laparoscopic presacral neurectomy, which was relieved easily by medication. CONCLUSION: Presacral neurectomy can be performed safely and efficiently by laparoscopy and is a valuable alternative treatment for pelvic pain.

Adolescent↗

PubMed1995

[Surgical treatment of cervical disk displacement. Anterior or posterior approach?].

PURPOSE OF THE STUDY: This study is a retrospective analysis of the treatment of cervical soft disc herniation comparing anterior and posterior approach. MATERIAL AND METHODS: Twenty eight patients presenting with cervico-brachial radiculopathy secondary to acute soft posterolateral disc herniation were reviewed. Cases with myelopathy or radiculopathy secondary to chronic spondylosis were excluded. Involved level was C5-C6 or C6-C7 in most cases. There were 14 females and 14 males. Age at operation averaged 44 years. Fourteen patients underwent an anterior approach with discectomy and fusion using autologous iliac bone graft. Average age was 46 years in this group with an average follow-up of 30 months. Average duration of surgery was 2 hours. Average hospital stay was 6 days. Fourteen patients underwent a posterior approach with partial lateral laminotomy extending medially for several millimeters over the facet joint. Extruded disc material was removed in 10 cases. No curettage was performed. Average age at surgery was 41 years with an average follow-up of 36 months in this group. Average duration of surgery was 70 minutes. Average hospital stay was 6 days. RESULTS: Patients were evaluated 3 months post-operatively and at their maximum follow-up. At 3 months follow-up, no patient complained of radicular pain; occasional cervical pain was present in 5 cases following posterior surgery but was not observed at late follow-up. Return to work was possible on an average of 3 months in both series. Results were graded as excellent, good, fair and poor. At late follow-up, in patients with a posterior approach, there were 8 excellent results, 5 good results with neck fatigue at work, and 1 fair result requiring analgesics. In patients with an anterior approach, there were 7 excellent results, 6 good results, and 1 fair result. Two patients complained of pain at the iliac donor site. DISCUSSION: These results suggest that the anterior approach gives better short term results, but no significant difference is observed between anterior and posterior approaches a few years after surgery. Although the anterior approach is more appropriate than the posterior one for the treatment of central disc herniation, the posterior approach may be considered as an alternative to anterior discectomy and fusion for antero-lateral soft disc herniation.

Adult↗

PubMed1994

Long-term neuropathy after regional isolated perfusion with melphalan for melanoma of the limbs.

The incidence of long-term (> or = 3 months) neuropathy in 350 melanoma patients treated with single normothermic or 'mild' hyperthermic perfusion with melphalan in the period 1978 to 1990 was studied. Long-term neuropathy was encountered in 14 patients; in 10/51 patients (20%) after perfusion at the axillary level and in 4/247 patients (2%) after perfusion at the iliac level. After brachial and femoro-popliteal perfusions no long-term neuropathy was observed. Neuropathy, mainly consisting of paresis/paralysis of the hand and/or fingers, anaesthesia, and/or paraesthesiae, improved over a mean period of 16 (3-43) months in eight patients, but three patients still had serious neuropathy one year after perfusion. In another six patients little improvement was seen and four died with permanent neuropathy. Acute regional toxicity after perfusion and the application of 'mild' hyperthermia did not seem to influence the incidence of long-term neuropathy. This complication is probably a result of the isolating Esmarch rubber bandage being applied too tightly during perfusion at a proximal level. At the axillary level, where the brachial plexus lacks the protection from enveloping tissues, nerve damage is especially prone to occur. We recommend applying this bandage no tighter than is necessary to maintain the isolation of the circuit. This implies meticulous surgical isolation of the vascular system and accurate monitoring of leakage.

Adolescent↗

PubMed2003

Surgical techniques for total sacrectomy and spinopelvic reconstruction.

The surgical management of sacral tumors requires partial or total sacrectomy and spinopelvic reconstruction. These lesions present a great surgical challenge, because most spine surgeons are unfamiliar with the techniques required for these procedures. The authors describe a step-by-step operative technique and provide several illustrations. Total sacrectomy is performed by sequential anterior and posterior approaches that involve a rectus abdominis pullthrough pedicle flap reconstruction. The anterior procedure is an intraperitoneal approach used to expose the anterior aspect of the tumor, to ligate the main tumor vessels, and to conduct an anterior partial sacrectomy. After this, the rectus abdominis myocutaneous flap, based on the inferior epigastric vessel, is prepared, and a posterior sacrectomy is performed, dividing all sacral nerve roots in the thecal sac. After complete en bloc extirpation of the sacrum with tumor, spinopelvic reconstruction and closure with a myocutaneous flap are performed. Spinopelvic reconstruction is undertaken using a modified Galveston technique or double iliac screw fixation combined with posterior lumbar segmental fixation. These provide a long lever arm within the ilium to counteract the forces exerted by the lumbar spine. Understanding the nature of the disease as well as the biomechanics of the lumbosacral pelvic area and spinopelvic fixation will help surgeons select the appropriate treatment for sacral tumors.

Biomechanical Phenomena↗

PubMed1996

Totally extraperitoneal laparoscopic lumbar sympathectomy: an initial case report.

A 27-year-old man with a diagnosis of Buerger's disease presented with vasospastic symptoms of coldness and pain at rest of his right foot. Physical examination of his affected limb revealed absent popliteal pulse, cool skin hyperhidrosis and dry gangrene of the big toe. He had been operated on for a ruptured liver and liver abscess 20 years ago. He was scheduled for totally extraperitoneal laparoscopic lumbar sympathectomy on July 26, 1994. The technique was performed under general anesthesia and the patient was put in a supine position with slight extension between the rib and the iliac crest. The working space was created by digital blunt dissection and direct insufflation of carbon dioxide. The right sympathetic trunk was found between the medial edge of the psoas muscle and inferior vena cava. The L2, L3, L4 sympathetic ganglia were identified above the vertebral column and meticulously dissected cephalocaudally. Based on the concept of traditional approach, we believe that this laparoscopic technique is relatively safe and should become the procedure of choice in the future.

Adult↗