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PubMedDate not supplied

A reappraisal of the anatomy of the levator ani muscle in man.

A study of the attachments of the musculotendinous fibres of the levator ani muscle shows that it is made of two portions: a thick anterior portion which is mostly fleshy and a thin posterior portion which is mostly aponeurotic. The anterior portion consists of two layers: a superficial perineal layer and a deep pelvic layer. Both layers have a common origin from the back of the body of the pubic bone and the anterior part of the tendinous arch. In addition both layers make a U-shaped loop around the recto-anal junction. The posterior fibres of the deep pelvic layer received nerve supply only from the third and fourth sacral nerves. The rest of the muscle was supplied from the sacral nerves as well as the perineal branches of the pudendal nerve. The role of the anterior fibres in reinforcing the sphincters of the anal canal and fixation of the pelvic viscera is stressed. The close anatomical relation between the posterior portion of the muscle and the obturator internus suggests that the latter may play a role in supporting the weak posterior portion of the levator ani, especially during straining positions associated with lateral rotation at both hips.

Adult↗
PubMed1987

Projections of visceral and somatic primary afferents to the sacral spinal cord of the domestic fowl revealed by transganglionic transport of horseradish peroxidase.

The termination of visceral and somatic primary afferent fibers in the sacral spinal cord of the domestic fowl was studied using transganglionic transport of horseradish peroxidase. Nerve terminals of visceral afferent fibers were found in the lateral edge and base of the dorsal horn and in the dorsal gray commissure in close proximity to parasympathetic preganglionic neurons. Somatic afferents terminated in laminae 2 and 3. The results demonstrate that visceral and somatic afferent fibers in this avian species terminate in different areas of the dorsal horn.

Animals↗
PubMed2000

Sacral neural crest cell migration to the gut is dependent upon the migratory environment and not cell-autonomous migratory properties.

Avian neural crest cells from the vagal (somite level 1-7) and the sacral (somite level 28 and posterior) axial levels migrate into the gut and differentiate into the neurons and glial cells of the enteric nervous system. Neural crest cells that emigrate from the cervical and thoracic levels stop short of the dorsal mesentery and do not enter the gut. In this study we tested the hypothesis that neural crest cells derived from the sacral level have cell-autonomous migratory properties that allow them to reach and invade the gut mesenchyme. We heterotopically grafted neural crest cells from the sacral axial level to the thoracic level and vice versa and observed that the neural crest cells behaved according to their new position, rather than their site of origin. Our results show that the environment at the sacral level is sufficient to allow neural crest cells from other axial levels to enter the mesentery and gut mesenchyme. Our study further suggests that at least two environmental conditions at the sacral level enhance ventral migration. First, sacral neural crest cells take a ventral rather than a medial-to-lateral path through the somites and consequently arrive near the gut mesenchyme many hours earlier than their counterparts at the thoracic level. Our experimental evidence reveals only a narrow window of opportunity to invade the mesenchyme of the mesentery and the gut, so that earlier arrival assures the sacral neural crest of gaining access to the gut. Second, the gut endoderm is more dorsally situated at the sacral level than at the thoracic level. Thus, sacral neural crest cells take a more direct path to the gut than the thoracic neural crest, and also their target is closer to the site from which they initiate migration. In addition, there appears to be a barrier to migration at the thoracic level that prevents neural crest cells at that axial level from migrating ventral to the dorsal aorta and into the mesentery, which is the portal to the gut.

Animals↗
PubMed2001

Non-invasive antidromic neurostimulation: a simple effective method for improving bladder storage.

Patients with intractably diminished bladder storage function are encountered frequently by neurourologists, occasionally requiring reconstructive surgery for appropriate resolution. Although sacral neuromodulation is a recognized effective therapeutic modality, present techniques are technically demanding, invasive, and expensive. This study investigated the effect of non-invasive third sacral nerve (S3) stimulation on bladder activity during filling cystometry. One hundred forty-six patients underwent standard urodynamic filling cystometry that was then immediately repeated. Patients in the study group (n = 74) received antidromic transcutaneous sacral neurostimulation during the second fill and the control group (n = 72) underwent a second fill without neurostimulation. A statistically significant increase in bladder storage capacity without a corresponding rise in detrusor pressure was observed in the neurostimulated patients. This improvement in functional capacity is an encouraging finding that further supports the use of this non-invasive treatment modality in clinical practice.

Adolescent↗
PubMed2004

Reliability of electrophysiologic anal tests in predicting the outcome of sacral nerve modulation for fecal incontinence.

INTRODUCTION: Sacral nerve modulation has been demonstrated to be a new efficacious treatment for fecal incontinence. The effectiveness of the procedure is preliminarily tested by means of a peripheral nerve evaluation. Integrity of the sacral neural pathway is generally believed to be a necessary condition for a good response, but no data are available to confirm whether electrophysiologic anal tests are predictive of the clinical outcome of the peripheral nerve evaluation. METHODS: Eighty-two incontinent patients underwent the peripheral nerve evaluation after full evaluation of the anorectal physiology. Univariate analysis was performed, and the positive predictive value, sensitivity, and specificity were calculated for each of the tests. RESULTS: Forty-six patients had successful results to the peripheral nerve evaluation and were subjected to permanent implant of a sacral electrostimulator. Anal sphincter electromyography had been performed in 60 patients, whereas pudendal nerve terminal motor latency had been assessed in 68 and evoked sacral potentials in 29 patients. Anal electromyography was statistically related to the outcome of the peripheral nerve evaluation ( P = 0.0004) with a positive predictive value of 81 percent, a sensitivity of 44 percent, and a specificity of 81 percent. Pudendal nerve terminal motor latency on the right side did not correlate with the outcome, but left pudendal nerve terminal motor latency was weakly correlated ( P = 0.02), although both tests had a low positive predicting value and sensitivity vs. good specificity. Evoked sacral potentials did not correlate with the outcome and had a low positive predictive value, sensitivity, and specificity. CONCLUSIONS: Simple anal sphincter electromyography can predict the outcome of the peripheral nerve evaluation with good positive predictive value and specificity in patients with fecal incontinence. Other, more expensive, electrophysiologic anal tests do not add further prognostic information.

Aged↗
PubMed1998

Specific targeting of ganglion cell sprouts provides an additional mechanism for restoring peripheral motor circuits in pelvic ganglia after spinal nerve damage.

The pelvic ganglia contain both sympathetic and parasympathetic neurons and provide an interesting model in which to study the effects of a distributed spinal nerve lesion. Previous animal studies have suggested that after either lumbar or sacral nerve injury, some functional connections are restored between preganglionic and postganglionic neurons. It has been proposed that this is because of intact preganglionic axons sprouting collaterals to supply denervated ganglion cells. However, this has never been demonstrated, and our study has investigated whether the ganglion cells themselves contribute to axogenesis and restoration of peripheral circuitry. We have monitored the growth of axons from pelvic ganglion cells after lumbar or sacral nerve injury (partial decentralization), or a combination of the two (total decentralization). These new processes were distinguished from intact preganglionic terminals by their immunoreactivity for substances present only in pelvic ganglion neurons (vasoactive intestinal peptide, neuropeptide Y, and tyrosine hydroxylase). The proportion of pelvic neurons surrounded by these immunostained fibers was then assessed. Complete removal of preganglionic terminals provides the biggest stimulus for growth of new axon processes (sprouts), which grow profusely within just a few days. These arise from each of the main chemical classes of pelvic neurons but grow at different rates and have different distributions. Importantly, some chemical classes of sprouts preferentially supply neurons of dissimilar histochemistry, suggesting the presence of very specific targeting mechanisms rather than random growth. These sprouts are transient, however, those formed after partial decentralization appear to be maintained. Moreover, after lesion of either lumbar or sacral spinal nerves, many sprouts arise from neurons with intact spinal connections and innervate neurons that have lost their preganglionic inputs. This provides a very different alternative mechanism to reestablish communication between preganglionic and postganglionic neurons. In conclusion, we have demonstrated a rapid and selective axogenesis within the pelvic ganglion after spinal nerve injury. This may allow the development of novel strategies by which autonomic nerve pathways can be experimentally manipulated, to facilitate more rapid return of appropriate peripheral reflex control.

Animals↗
PubMedDate not supplied

Resection of a pelvic schwannoma with partial removal of the sacral nerve root.

Because the symptoms do not appear in most cases until the tumor has grown quite large, schwannomas are often detected incidentally during work-up for some other condition. Benign schwannomas generally do not invade adjacent structures but making the diagnosis preoperatively can be difficult when the tumor is large. We report the case of a benign schwannoma which was diagnosed preoperatively by needle core biopsy under computed tomography guidance. The tumor was removed completely by partially resecting the S1 nerve root, which was subsequently reanastomosed. The postoperative course was uneventful with the exception of minimal left leg pain due to neurologic deficit.

Female↗
PubMed2001

Sacral nerve neuromodulation in the treatment of refractory motor urge incontinence.

Sacral nerve neuromodulation may be an effective treatment option in patients with motor urge incontinence when conservative therapy fails. The effect of treatment is durable in the majority of patients, but there is also a high failure rate. The cause of failure remains unclear in most cases as it is still unknown exactly how neuromodulation works. The present review summarizes the results of patient treatment and research into the working mechanism of neuromodulation, as well as the technical developments described in the past year.

Electric Stimulation Therapy↗
PubMed1990

The human vertebral column at the end of the embryonic period proper. 4. The sacrococcygeal region.

The sacral and coccygeal vertebrae at 8 postovulatory weeks (the end of the embryonic period proper) have been studied by means of graphic reconstructions. The cartilaginous sacrum is now a definitive unit composed of five separable vertebrae, each of which consists of a future centrum and bilateral neural processes. The base of each neural process consists of an anterolateral or alar element, not present in the lumbar region, and a posterolateral part, which includes costal and transverse elements. The usual illustrations, in which the costal component is placed in the alar element, are incorrect. The future dorsal foramina (containing dorsal rami) face laterally in the embryo and are in line with the thoracicolumbar intervertebral foramina. Considerable differential growth is required to change the dorsal openings from a lateral to a dorsal positions. The intervertebral foramina transmit ventral rami, but pelvic foramina are not yet present. The lumbosacral plexus is completed by S.N.1-3; S.N.4, 5 and Co.N.1 form the pelvic plexus. The inferior hypogastric plexus and the hypogastric nerves are present. The sacrum takes part in the spina bifida occulta that characterises the entire length of the embryonic vertebral column. The coccygeal vertebrae, which are variable, were 4-6 in number in the present series. The first is the best developed. The ventriculus terminalis ends usually at the level of Co.V.1 and the spinal cord generally at Co.V.5. The coccygeal notochord ends commonly in bifurcation or trifurcation. 'Haemal arches' were not observed.

Anthropometry↗
PubMed1999

Sacroiliac joint innervation and pain.

The present paper reviews current knowledge on the innervation of the human sacroiliac joint (SIJ). We conclude, based on a recent anatomic study on adult cadavers, with fetal correlation, that the joint is predominantly, if not entirely, innervated by sacral dorsal rami. This conclusion is in agreement with patterns of referred pain reported by asymptomatic volunteers upon direct SIJ capsular stimulation and with a reduction in pain in patients treated for (presumptive) SIJ pain by injection of an anesthetic into the SIJ. We also present preliminary data suggesting that the periarticular tissues of the SIJ, like those of other synovial joints, contain mechanoreceptors and nociceptors that function to inform the central nervous system about the state of the joint.

Adult↗
PubMed2006

[A case of far-out syndrome: case report and review of the literature].

Far-out syndrome (FOS) is a rare disease in which the L5 nerve root is compressed by a transverse process, the sacral ala, and a bony spur at the extraforaminal zone. We report the case of patient with FOS due to a bulging disc and review the literature. This 34-year-old male experienced severe left leg pain and slight motor weakness of the left extensor digitorum. Radiographic studies revealed no abnormality in the spinal canal. The intervertebral disk bulged to the left. Because of fat it was difficult to discern the left L5 nerve root from the sacral ala in the extraforaminal zone. His symptoms failed to respond to conservative treatment and he underwent decompression of the L5 nerve root without fusion. During the operation, the left L5 nerve root was exposed by drilling the sacral ala via the left paraspinal approach. The sacral ala was removed along with the left L5 nerve root to obtain sufficient pulsation and movement of the left L5 nerve root. Neither the intervertebral joint nor the intervertebral disk was removed. The patient's symptoms disappeared immediately after surgery. Due to anatomical factors, the L5 nerve root is easily compressed and the presence of this syndrome should be considered in a differential diagnosis. Careful and appropriate decompression without fusion yielded an excellent outcome.

Adult↗
PubMed1980

Studies on sacral-evoked potentials.

The bulbocavernosus reflex may be evoked electrically with a latency of approximately 35 msec. in normal male subjects. We have studied the sacral-evoked response in 116 individuals, 10 of whom were normal controls. For each study ipsilateral and contralateral responses were obtained from each side, resulting in 4 latency values. We herein describe the abnormalities in 54 patients with a variety of documented neurologic lesions. Our investigation reveals that the bulbocavernosus reflex has the characteristics of a cutaneous polysynaptic bilateral flexor response. The use of bilateral stimulation and recording techniques permits more effective localization of neurologic lesions involving the conus medullaris or cauda equina roots.

Electric Stimulation↗
PubMed1990

[Peripheral neurofibromatosis and involvement of lumbosacral nerves. Value of imaging].

We report a case of giant plexiform neurofibromatosis revealed by a sensori-motor, axo-myelinic polyneuropathy. Only the lumbar and sacral spinal nerves were involved in this peripheral form of Von Recklinghausen's disease. The polyneuropathy was due to compression of the nervous fibers by the neurofibromatous tumors. Ultrasonography DTPA 99 m Technetium scintigraphy, CT and MRI were the diagnostic procedures. MRI proved superior to CT in demonstrating the extent of the lesions. Biopsy confirmed the diagnosis. This form of neurofibromatosis did not involve the central nervous system, cranial nerves of cervicothoracic spinal nerves and roots; nor was there any visceral involvement, particularly endocrine neoplasia.

Adult↗
PubMed1976

Management of the uninhibited bladder by selective sacral neurectomy.

The authors report the treatment of incontinence due to uninhibited bladder contractions by selective sacral neurectomy in nine patients, four without evidence of neurological disease. A detailed and objective analysis of bladder and urethral function, together with quantitation of clinical features, was made before and after operation. Seven patients were either cured or greatly improved. The overall increase in bladder capacity and reduction of uninhibited activity were statistically significant. The resting urethral sphincter pressure was unchanged, but the contractility of the voluntary external sphincter was slightly impaired. Criteria for such neurectomies are discussed.

Anesthesia, Caudal↗
PubMed1991

Enteric glia.

The structure of the enteric nervous system (ENS) is different from that of extraenteric peripheral nerve. Collagen is excluded from the enteric plexuses and support for neuronal elements is provided by astrocyte-like enteric glial cells. Enteric glia differ from Schwann cells in that they do not form basal laminae and they ensheath axons, not individually, but in groups. Although enteric glia are rich in the S-100 and glial fibrillary acidic proteins, it has been difficult to find a single chemical marker that distinguishes enteric glia from non-myelinating Schwann cells. Nevertheless, two monoclonal antibodies have been obtained that recognize antigens that are expressed on Schwann cells (Ran-1 in rats and SMP in avians) but not enteric glia. Functional differences between enteric glia and non-myelinating Schwann cells, including responses to gliotoxins and in vitro proliferative rates, have also been observed. Developmentally, enteric glia, like Schwann cells, are derived from the neural crest. In both mammals and birds the precursors of the ENS appear to migrate to the bowel from sacral as well as vagal levels of the crest. These crest-derived emigrés give rise to both enteric glia and neurons; however, analyses of the ontogeny of the enteric innervation in a mutant mouse (the ls/ls), in which the original colonizing waves of crest-derived precursor cells are unable to invade the terminal colon, suggest that enteric glia can also arise from Schwann cells that enter the gut with the extrinsic innervation. When induced to leave back-transplanted segments of avian bowel, enteric crest-derived cells migrate into peripheral nerves and form Schwann cells. Enteric glia and Schwann cells thus appear to be different cell types, but ones that derive from lineages that diverge relatively late in ontogeny.

Animals↗
PubMed1991

Dysfunctional uterine bleeding with concomitant low back and lower extremity pain.

In this case presentation, a temporal relationship between conservative chiropractic care and dysfunctional uterine bleeding (DUB) in a patient with mild low back and primary leg pain is described. Criteria are discussed to establish protocol that will be useful in the formulation of a diagnosis for DUB secondary to lower sacral nerve root compression and lumbar mechanical dysfunction. There have been investigations recently published that suggest a positive relationship between chiropractic lumbar, closed reduction distractive decompression (CRDD) and patients with pelvic pain and organic dysfunction. This case study presents the treatment response of one patient with one form of somatovisceral dysfunction, namely, dysfunctional uterine bleeding, in the absence of pelvic pain. Conservative chiropractic care may be an effective, noninvasive method for treating some individuals with dysfunctional uterine bleeding, caused secondarily from biomechanical and/or neurological insult. Further research in this area is encouraged.

Adult↗
PubMed2000

[Associated injuries in severe pelvic trauma].

There has been a marked increase in the incidence of pelvic fractures over the last few years. Associated injuries to the urogenital and vascular system as well as nerve injuries worsen the prognosis. Over a five year period 126 patients with severe pelvic trauma were treated. Out of these 39 (30.9%) sustained additional peripelvic injuries and represent the study sample. Type B injuries according to the AO classification occurred in 16 (41%) patients, type C fractures in 23 (59%) patients. The spleen, liver and kidney were the most frequently injured organs (58.9%), followed by urogenital lesions (46.6%), nerve injuries (25.6%) and vascular lesions (15.3%). The most common extrapelvic lesions were thoracic injuries in 56.4% and severe head injuries (GCS < 8) in 33.3%. The mean Hannover Polytrauma score was 35.6 points, the mean Injury Severity Score 27.6 points. Osteosynthesis was performed in 21 pelvic ring fractures (53%), eight procedures (50%) in type B fractures and 13 (56%) in type C fractures. In type B injuries the anterior pelvic ring was stabilized with a tension band wiring in four cases, in two patients with an external fixator and with plate osteosynthesis in one case. In type C injuries the external fixator was applied as the only stabilizing procedure in six patients. In four cases the anterior ring was fixed with tension band wiring or plates and the dorsal aspect of the pelvic ring with sacral bars. Three patients had their additional acetabular fracture plated through a anterior approach. All surviving 28 patients were followed up for an average of 18 months (range 7-59 months) after the trauma. The patients were classified using the pelvic outcome score proposed by the German Society of Trauma Surgery. 53.4% of the type B fractures showed a good clinical outcome, 47.6% a poor outcome. 15.4% with type C fractures presented with a good outcome, 84.6% with a poor outcome. 80% of the type B and 23% of the type C fractures had a good radiological outcome. 20% of type B and 77% of type C injuries had a poor radiological outcome. Five patients (12.8%) sustained persistent urological symptoms. Three of these had urinary dysfunction, two used permanent cystotomies due to their severe neurological deficit after a head injury. Ten patients with nerve injuries at the time of trauma suffered long term neurological dysfunction of the lumbosacral plexus. The mortality rate was 28%. Seven patients died in the emergency room due to uncontrollable bleeding, four in the intensive care unit from multi-organ failure. The management of complex pelvic trauma consists of fracture treatment and interdisciplinary treatment of the associated injury. Lesions of the abdominal organs or of major vessels must be addressed first if hemodynamic instability is present. Injuries to smaller vessels can be embolized percutaneously. Urinary bladder ruptures are treated as an emergency, urethral lesions electively after four to six weeks. We recommend external fixation of the pelvis in the acute phase for control of both the osseous instability and control of haemorrhage through external compression. The treatment of choice for the anterior pelvic ring is tension band wiring or plating. If this is contraindicated due to an open fracture external fixation is the treatment of choice. Type C fractures require posterior ring stabilization which should be postponed until four days post admission.

Abdominal Injuries↗
PubMed1978

Sacral rootlet rhizotomy at the conus medullaris for hypertonic neurogenic bladder.

Three patients with spastic neurogenic bladder underwent sacral root stimulation and appropriate section of motor rootlets to the detrusor at the levels of the conus medullaris. Compared to the results obtained with rhizotomies at the sacral levels in a previous series of patients, urinary frequency and infection were inhibited for longer periods of time, but some uninhibited bladder activity recurred in all three patients. Analysis of anatomical and electrophysiological data serves to emphasize the complexity and asymmetry of efferent supply to detrusor muscle. The authors conclude that the role of selective rhizotomy for inhibition of the spastic bladder is inconclusive, and perhaps a combination of surgery and medications that inhibit smooth-muscle contraction may be required for long-term protection of urinary collection systems.

Adult↗