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PubMed2001

[Loco-regional anaesthesia of the lower limbs].

Lumbar plexus and sacral plexus are responsible for sensory and motor innervation of the whole inferior limb and their blockade can be used as a single technique or integrated with general anaesthesia for hip-, femur-, knee-, lower leg-, ankle- and foot surgery. For the performance of the blocks, knowledge of peripheral and central percourse of the nerves and their anatomical relationships to bone-, muscle-, vessel and skin structures is important. In case of the sciatic nerve, a cutaneous projection of the percourse of the nerve is possible (the so-called sciatic line) formed by a virtual line from the midpoint of the line between great trochanter and ischial tuberosity to the apex of the popliteal fossa. Peripheral blocks used for the above mentioned types of surgery are: lumbar plexus block, sacral plexus block, femoral nerve block, obturator nerve block, lateral cutaneous femoral nerve block and sciatic nerve block. Regarding the last one, the following approaches are possible, depending on the anatomical site of performance: classic proximal posterior block, parasacral proximal block, lithotomic posterior proximal block, subgluteal posterior proximal block, anterior proximal block, lateral medio femoral popliteal proximal block, block distal from the poplitea, subcalcaneal block. The terms distal and proximal are in relation to the small trochanter. All blocks have to be performed using a nerve stimulator, teflon insulated needles of various measures depending on the kind of block, variable stimulation from 1,5 mA (when evoking muscle contraction) to 0,5-0,3 mA (injection of local anaesthetic) with frequencies of 2 Hz/0,1 ms.

Anesthesia, Local↗
PubMed2005

Microsurgical treatment of lumbosacral plexus injuries.

Surgical treatment of lumbar and sacral plexus lesions is very rarely reported in the literature. The incidence of the involvement of these nervous structures in traumatic lesions of different etiology is probably much higher than believed, and surgical treatment should be taken into consideration more often. In this paper the experience derived from the surgical treatment of 15 cases is reported. Different surgical approaches have been employed according to ethiology, to level of nerve lesion and concomitant lesions of other organs. Patients who suffered a lesion in the lumbar or sacral plexus may have a very severe problem with deambulation since the leg may not be stable or may be unable to withstand the weight of the body. Pain syndrome in these patients may be a very severe obstacle to rehabilitation programs and to deambulation and everyday activity. Microsurgical nerve treatment in the retroperitoneal space is demanding both for the surgeon and for the patient but neurolysis and grafting procedures are possible also in this area. The resulting improvement of motor performance and the relief of pain are strong arguments in favor of this choice. Muscles benefitting most from surgery are the gluteal and femural muscles; more distant muscles, and particularly the anterior tibial nerve dependent muscles will gain minimal benefit from surgery. The relief from pain is relevant in all cases.

Adolescent↗
PubMed2003

The inferior hypogastric plexus (pelvic plexus): its importance in neural preservation techniques.

The progress in the surgery of male neurological cancers relies on the anatomico-surgical approach to the pelvic neural structures. The objective of our study was to provide a better understanding of the inferior hypogastric plexus (IHP) and its anatomical relationships in order to spare it during radical prostatectomy. Fifteen male formalin-preserved cadavers which had no sub-umbilical scar were used. In five subjects, the superior hypogastric plexus (SHP) and the pre-sacral plexus were displayed then the IHP and its sacral afferents (pelvic splanchnic nerves or erector nerves of Eckhardt) were dissected out. Serial sections of the IHP were then studied in ten subjects. This allowed its identification on certain imaging sections obtained in pelvic tumor pathology and these made up the "reference cuts". The IHP lies within a fibro-fatty plate which is flat, rectangular, sub-peritoneal, sagittal and symmetrical. It arises at the level of the intersection between the vas deferens and the terminal pelvic ureter and follows the postero-lateral aspect and circumvolutions of the seminal vesicle, with which there is a plane of surgical cleavage. The seminal vesicle is, therefore, an essential landmark for this neural structure. The plane of this cleavage may be used in pelvic cancer surgery. The safest technical means of respecting sexual function and the integrity of the IHP is to keep it at a distance. The preservation of a lateral layer of the seminal vesicle is probably a method of limiting these complications as long as this does not conflict with the oncological clearance. An irregular communicating branch was found in one of five cases between the IHP, the sacral plexus and the pudendal nerve. This communicating branch lay immediately behind the intersection between the vas deferens and the ureter in the sacral concavity. It overhangs the IHP in the seminal vesicle. Impotence remains a frequent complication after radical prostatectomy. The methods of neural preservation at the prostatic apex are known but neural preservation should also be carried out posteriorly at the lateral pole of the seminal vesicle. The possibility of posterior neural preservation may be assessed pre-operatively by study of the "reference sections". The cleavage plane between the seminal vesicle and the IHP may be used intra-operatively to spare the IHP. The cavernous nerve in particular emerges at the antero-inferior border of the IHP before running along the postero-lateral aspect of the prostate. It therefore passes in contact with the seminal vesicle and may as a result be injured during radical prostatectomy with vesiculectomy. A proximal communicating branch between the IHP and the pudendal nerve is irregular. Such communicating branches may explain a better recovery of sexual function in curative neurological cancer surgery. The essential relationship of the IHP is with the seminal vesicle. The two are in tight contact and the seminal vesicle has a true plane of surgical cleavage with IHP. The risk of injuries to the posterior erectile mechanisms can be reduced either by using the cleavage plane between the IHP and seminal vesicle or by leaving a layer of the seminal vesicle when the oncological conditions allow. During celio-surgery, the operator must be careful to retract the little bands of the seminal vesicle and divide the fibrous and vascular tracts which tighten during this maneuver. During an abdominal approach, dissection of the seminal vesicle takes place at the bottom of a real pit. The operator must carry out the division leaving a layer of the seminal vesicle in place rather than trying to extract all the seminal vesicle by placing the forceps blindly. This maneuver is naturally dependent on the oncological situation. The anatomical confirmation of a regular or irregular proximal or distal communicating branch between the IHP and the pudendal nerve is probably an explanation for the sometimes uncertain results of new techniques of neural preservation in curative cancer surgery.

Aged↗
PubMed2005

Anatomical study of the pudendal nerve adjacent to the sacrospinous ligament.

The pudendal nerve (S3-S5) is a major branch of the sacral plexus. After branching from the sacral plexus, the pudendal nerve travels through three main regions: the gluteal region, the pudendal canal, and the perineum. In the gluteal region, the pudendal nerve lies posterior to the sacrospinous ligament. The relationship of the pudendal nerve to the sacrospinous ligament has important clinical ramifications, but there is a lack of literature examining the variations in pudendal nerve anatomy in the gluteal region. This study investigates the pudendal nerve trunking in relation to the sacrospinous ligament in 37 cadavers (73 sides of pelves) of 21 males and 16 females, ranging from 18-83 years of age. Pudendal nerve trunking could be grouped into five types: Type I is defined as one-trunked (41/73; 56.2%), Type II is two-trunked (8/73; 11%), Type III is two-trunked with one trunk as an inferior rectal nerve piercing through the sacrospinous ligament (8/73; 11%), Type IV is two-trunked with one as an inferior rectal nerve not piercing through the sacrospinous ligament (7/73; 9.5%), and Type V is three-trunked (9/73; 12.3%). In summary, 56.2% of pudendal nerves adjacent to the sacrospinous ligament were one-trunked, 31.5% were two-trunked and 12.3% were three-trunked. Fifteen inferior rectal nerves originated independently from the S4 root and never joined the main pudendal nerve. Eight of fifteen inferior rectal nerves pierced through the sacrospinous ligament, perhaps making it prone for entrapment. We measured the average diameter of the main trunk of the pudendal nerve to be 4.67 +/- 1.17 mm. We also measured the average length of the pudendal nerve trunks before terminal branching to be 25.14 +/- 10.29 mm. There was no significant statistical difference in the average length, average diameter, number of trunks, and pudendal nerve variations between male and female or right or left sides of the pelves. A detailed study of pudendal nerve trunking in relationship to the sacrospinous ligament would be useful for instruction in basic anatomy courses and in relevant clinical settings as well.

Adolescent↗
PubMed1995

Muscles of the pelvic outlet in the rhesus monkey (Macaca mulatta) with special reference to nerve supply.

BACKGROUND: The manner of innervation of the muscles of the inferior limb, pelvic outlet, and tail in rhesus monkey (Macaca mulatta) was investigated in detail in 11 pelvic halves of four males and two females. RESULTS: The origins of the pudendal nerve were widespread and overlapped the sacral plexus. After removal of the bone structures, detailed dissection revealed the origin of the pudendal nerve to ventrocaudally overlap the sacral plexus. This dorsoventral branching pattern between the sacral plexus and the pudendal nerve is similar to that in Urodela (Akita, 1992b), Lacertilia (Akita, 1992a) and Aves (Akita et al., 1992a), and is a basis for morphological understanding of the muscles of the pelvic outlet. CONCLUSIONS: The muscles of the pelvic outlet consist of the levator, sphincter, and tail muscle groups, based on the stratification of the supplying nerves the former two groups likely derive from the ventral muscles of the inferior limb, and the latter group from the ventral caudal (trunk) muscles.

Anatomy, Artistic↗
PubMed1994

[Perforation of dorsal branches of the sacral nerve plexus through the piriformis muscle and its relation to changes of segmental arrangements of the vertebral column and others].

To determine whether perforation of the dorsal branches arising from the sacral nerve plexus through the piriformis muscle is dependent on segmental migration of the vertebral column and others, the relationships between the perforating nerves (Fig. 1) and changes in the segmental composition of the following items were studied morphologically and statistically in 224 Japanese adults. Each of items 1) to 8) was classified in some mode or type depending on its composition and appearance. 1) Based on the length of the 8th rib and costal cartilage and whether or not the 8th to 10th ribs attached to the costal arch, the forms of the arch were classified into 6 types (Fig. 2-1). Type E, quoted commonly in many textbooks, in which the 8th to 10th ribs are all joined to the arch, was found in only 8 (6%) of 126 sides. A true 8th rib was found in 2 (3%), and a floating 10th rib was found in 59 (95%) of 62 sides. 2) The length of the 12th rib and costal cartilage, measured by a wet thread put on its inner surface, was classified into 4 types (Fig. 3-1): lacking (in this condition, the lumbar costal process appeared in 9 (2%) of 380 sides), short, normal (the length ranged from 5.1 cm to 13.4 cm) and long. Length varied from about 3 cm to 18.2 cm, with most cases concentrated in a range of 8 cm-14 cm. 3) Based on the number of presacral vertebrae, the vertebral column was classified as short (prefixed), normal, normal in number but abnormal in composition, and long (postfixed) (Table 4-1). The true "normal" type of 12 thoracic and 5 lumbar vertebrae was found in 196 (88%) of 224 bodies. Eleven thoracic and 5 lumbar, 13 thoracic and 4 lumbar, and 13 thoracic and 5 lumbar vertebrae were found in one body each, and thoracolumbar and lumbosacral vertebrae in 2 and 5 bodies, respectively. The long type of vertebral column appeared about twice as often as the short type. 4) Based on the height and appearance of the sacral promontory in the median plane, it was divided into 7 types (Fig. 5-1). The normal type, in which the promontory lay on the tip of the first sacral (25th) vertebra and projected sharply into the pelvic cavity, was found in 158 (71%) of 224 bodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Humans↗
PubMed2005

Lateral branches of dorsal sacral nerve plexus and the long posterior sacroiliac ligament.

Non-specific low back pain and peripartum pelvic pain have aetiologies that may feature the sacroiliac region. This region possesses many potential pain-generating structures sharing common sensory innervation which makes clinical differentiation of pathoanatomy difficult. This anatomical study explores the relationship between the long posterior sacroiliac ligament (LPSL) and the lateral branches of the dorsal sacral nerve plexus. Twenty-five sides of the pelvis from 16 cadavers were studied, three for histological analysis and 22 for gross anatomical dissection. We found that the LPSL is penetrated by the lateral branches of the dorsal sacral rami of predominantly S2 (96%, 21/22) and S3 (100%, 22/22), variably of S4 (59%, 13/22) and rarely of S1 (4%, 1/22). Some of the penetrating lateral branches give off nerve fibres that disappear within the ligament. These findings provide an anatomical basis for the notion that the LPSL is a potential pain generator in the posterior sacroiliac region.

Aged↗