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PubMedDate not supplied

Trans-femoral lumbar epidural venography.

Epidural venography is a relatively simple, safe and highly accurate method of diagnosing lumbar disc herniations. Good opacification of the epidural venous plexus can be obtained by selective catheterization of the ascending lumbar vein or pre-sacral branches of the internal iliac veins. Experience with 100 cases of lumbar disc herniations is described. The authors think that epidural venography is a more sensitive technique than myelography, particularly with lateral disc herniation at the L5-S1 level. It is not associated with the morbidity or complications of myelography and can be performed as an outpatient procedure. Epidural venography is recommended as the examination of choice in patients with suspected lumbar disc herniation.

Epidural Space↗

PubMed2006

Complications in paediatric anaesthesia.

PURPOSE OF REVIEW: This review identifies the most serious complications likely to be encountered in the current practice of paediatric anaesthesia. RECENT FINDINGS: The findings of the ASA Closed Claims Project, published in 1993, showed a higher proportion of closed paediatric malpractice claims related to respiratory events than to cardiovascular events. The Pediatric Perioperative Cardiac Arrest Registry--an offshoot of the American Society of Anesthesiologists Closed Claims Project--reviewed cardiac arrest data collected between 1994 and 1997, revealing a shift in the aetiology of cardiac arrest during paediatric anaesthesia over the past 20 years. The study found that reported cardiac arrests were now more prevalent from cardiovascular causes than respiratory causes, unlike the findings in the previous Closed Claims Project. Follow-up data collected by both the Pediatric Perioperative Cardiac Arrest Registry and the American Society of Anesthesiologists Closed Claims Project confirm this trend. SUMMARY: Outcomes for paediatric patients undergoing anaesthesia have improved over the years as a result of advances in monitoring and equipment, safer and more easily titratable anaesthetic agents, and possibly the practice of subspecialization. Preventable complications still, however, occur. An awareness of frequently encountered complications during paediatric anaesthesia may lead to the earlier detection and treatment of perioperative problems, leading to better outcomes.

Anesthesia↗

PubMed1999

Glycemic modulation of insulin/IGF-1 mediated skeletal muscle blood following sympathetic denervation in normal rats.

Both insulin and IGF-1 decrease vascular resistance and increase blood flow in skeletal muscle, and it has been suggested that the mechanistic action for insulin may be by increasing autonomic vasodilatory activity. In this study we evaluated the effects of insulin and IGF-1 on blood flow to denervated and non-denervated skeletal muscle as part of a continuing investigation into the mechanism of regulation of cardiovascular responses by these hormones. Normal rats were prepared for measurements of mean arterial pressure (MAP), heart rate (HR) and vascular flow in the left and right iliac artery. Resection of the left lumbar sympathetic chain increased flow (expressed as conductance, flow/MAP) in the denervated left iliac but not in the intact right artery. Subsequent insulin infusion where hypoglycemia was allowed to occur increased conductance in both arteries, but more so in the denervated artery. Similarly, IGF-1 infusion increased conductances in both intact and denervated iliac arteries, and the effect was slightly greater in the denervated artery. Insulin infusion when euglycemia was maintained increased conductance to a similar extent in denervated and intact iliac arteries. Contrastingly, IGF-1 infusion under euglycemic conditions resulted in a much greater increased conductance in the intact iliac. We conclude that both insulin and IGF-1 increase conductance directly and that glycemic status and sympathetic nerve activity modulate these responses. The insulin-induced increase in conductance in the denervated limb under hypoglycemic conditions suggest that hypoglycemic-stimulated epinephrine release may enhance the dilatory response. while the greater response to IGF-1 in the intact vessel under euglycemic conditions may be due to IGF-1 capacity to decrease sympathetic activity leading to an enhanced conductance.

Animals↗

PubMed1987

Regional nerve injury after intra-arterial chemotherapy.

Eleven patients at M.D. Anderson Hospital were referred for neurologic evaluation after having their internal or external iliac arteries catheterized for the treatment of localized pelvic or lower extremity tumors. Nine patients developed lumbosacral plexopathies and two patients, mononeuropathies. All symptoms occurred within 48 hours of the intra-arterial infusion. All patients received cis-dichlorodiammine-platinum (cisplatin; CDDP) intra-arterially, alone or in combination with other agents. Follow-up examinations revealed that only one patient had made partial recovery from the neurologic dysfunction. Chemotherapy-induced small vessel injury, with subsequent plexus or nerve infarction, appears to be the most likely cause, although a direct neurotoxic effect of CDDP cannot be excluded.

Adult↗

PubMed1982

Translateral retroperitoneal approach in radical surgery for pancreatic carcinoma.

Investigations of the lymphatic routes using dye during operations and histological studies on the resected specimen of the pancreas and autopsied cases with pancreatic carcinoma have led to the conclusion that the surgery should be performed more extensively to improve the results and should consist of a complete lymphatic excision surrounding the celiac axis and the trunk of the superior mesenteric artery including dissection of the nerve plexus and wide retroperitoneal dissection surrounding the pancreas, upwards to the level of adrenal glands, and downwards to the level of iliac bifurcation. A translateral retroperitoneal approach was found to be the most useful and safe method for such extended resection in patients with pancreatic carcinoma. Our radical procedure for pancreatic carcinoma is described herein.

Duodenum↗

PubMed1995

Morbidity and mortality following preoperative radiation therapy and total pelvic exenteration for primary rectal adenocarcinoma.

BACKGROUND: Pelvic exenteration, the standard treatment for patients with locally advanced rectal adenocarcinoma infiltrating neighbouring pelvic visceras, carried a significant morbidity and mortality rate. AIMS: The aim of this study was to determine the morbidity and mortality rates in a group of patients who were treated with preoperative radiation therapy and total pelvic exenteration. METHODS: Between January 1980 and January 1995, we treated 18 patients. Pretreatment staging was determined by clinical examination and computed tomography (CT) scan of the abdomen and pelvis. Each patient received preoperative radiation therapy of 45 Gy in 20 fractions delivered to the whole pelvis; approximately 6 weeks later total pelvic exenteration was performed. RESULTS: There were 17 males and 1 female, with a median age of 59 years. All patients underwent and completed the scheduled radiation therapy treatment. The main complaints related to radiotherapy were transient skin erythema in five patients and diarrhoea in four. Blood loss (estimated by the surgeon) ranged from 1000 ml to 4200 ml, with a mean loss of 2020 ml. Eight patients (44%) developed major complications: anastomatic leak from the uretero-intestinal suture line (n = 1); perineal wound infection (n = 2); abnormal wall infection (n = 1); haemorrhage from the right internal iliac vein (n = 1) and pneumonia (n = 1). Three patients required surgical reintervention for immediate postoperative haemorrhage from the sacral venous plexus (n = 1), small bowel obstruction (n = 1), and intra-abdominal and pelvic abscess (n = 1). There were two postoperative deaths (11%). The mean and median follow-up was 41 and 32 months, respectively. Two patients (12%) developed local recurrence at 5 and 8 months, and six developed distant recurrences (37%). The overall 5-year survival rate was 61%. CONCLUSION: Our treatment approach was associated with high morbidity and mortality rates, but was similar to previously published series based on total pelvic exenteration without prior radiation therapy. In addition, our therapeutic approach was associated with a low rate of overall local recurrences. Surgical Oncology 1995; 4: 295-301.

Adenocarcinoma↗

PubMed2006

Inferior vena cava thrombosis causing acute cauda equina syndrome. Case report.

The authors report a case of a 16-year-old girl who presented with a 1-week history of progressive low-back pain, buttock paresthesias, and bilateral lower extremity pain and weakness. Magnetic resonance (MR) imaging and MR venography studies of her lumbar spine revealed engorgement of the epidural venous plexus and mild compression of the cauda equina. A lower extremity and pelvic venogram revealed occlusive thrombosis of the femoral and iliac veins as well as of the inferior vena cava (IVC). The patient required an IVC thrombectomy due to progressive symptoms, after which she improved and returned to baseline status in 1 week. Imaging studies afterwards showed resolution of the venous engorgement and decompression of the cauda equina. This is the second published report of an association between IVC thrombosis and cauda equina syndrome.

Acute Disease↗

PubMed1990

Aorto-femoral reconstruction and sexual function: a prospective study.

The influence of aorto-femoral (AF) Dacron reconstruction on sexual function and pelvic circulation was studied prospectively in 62 male patients with aorto-iliac occlusive disease. Erectile function remained unchanged in 77%. Improvement or deterioration was seen in 11.3% and 20.5% of the cases respectively. Impotence occurred in only one patient (6%) with normal function preoperatively but in 31% of those presenting with impaired erection. Pelvic circulation, as reflected by the penile brachial index (PBI), was not affected in 74%, increased in 11% and decreased in 15% of the reconstructions. Pelvic circulation was at least preserved in 90% after an end-to-side proximal anastomosis and in 82% after an end-to-end anastomosis. Since fluctuations in sexual function could be related to changes in PBI in only 36% of the cases it is concluded that sexual disorders after AF surgery are due to a combination of disturbed pelvic haemodynamics and interruption of the preaortic autonomic plexus. Patients with impaired erectile function are especially at risk of a deterioration and the possibilities of restoring erectile function in patients with aorto-iliac stenosis by isolated AF reconstruction are limited.

Aorta, Abdominal↗

PubMed2001

Neurologic injury after endovascular stent-graft and bilateral internal iliac artery embolization for infrarenal abdominal aortic aneurysm.

The authors report a rare neurologic complication after the implantation of a bifurcated stent-graft for abdominal aortic aneurysm. The stent-graft was extended to both external iliac arteries after embolization of both internal iliac arteries. The patient subsequently had weakness and numbness of both lower limbs with bowel and bladder incontinence. He probably had ischemic injury to the nerve roots or the lumbosacral plexus, which was related to extensive occlusion of their supplying arteries. The mechanism of spinal cord and neurologic ischemia after aortic stent-graft implantation is discussed.

Aged↗

PubMed2002

Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go?

UNLABELLED: Continuous three-in-one block is widely used for postoperative analgesia after proximal lower limb surgery, but location of the catheter has not been well addressed in the literature. We prospectively studied, in 100 patients, the characteristics of catheter threading under the iliac fascia and the correlations between catheter tip location and effective sensory and motor blockade of the three principal nerves of the lumbar plexus. Postoperatively, in conscious patients, 16 to 20 cm of a catheter was placed in the fascial sheath after femoral nerve location with a nerve stimulator. Contrast media (3 mL Iopamidol 390) was injected, and the catheter tip was located by means of an anteroposterior pelvic radiograph. An equal-volume mixture of 0.5% bupivacaine/2% lidocaine with epinephrine (30 mL) was injected through the catheter. Patient and catheter-insertion characteristics were noted. Thirty minutes after injection, sensory blockade was evaluated in the cutaneous territories of the lateral femoral cutaneous, femoral, and obturator nerves, along with motor blockade of the last two nerves. Pain scores at 30 min were also recorded. Seven block failures were noted. The tip of the catheter reached the lumbar plexus (Group 1) in 23% of the patients and lay deep to the medial (Group 2) or lateral (Group 3) part of the fascia iliaca in 33% and 37% of the patients, respectively. Demographic data and catheter threading characteristics were comparable among the groups. A three-in-one block was noted in 91% of Group 1 patients, but in only 52% and 27% of Group 2 and 3 patients, respectively (P < 0.05). Comparing Group 2 and 3 patients, sensory block was achieved in respectively 100% and 94% for the femoral nerve, 52% and 94% for the lateral femoral cutaneous nerve (P < 0.05), and 82% and 27% for the obturator nerve (P < 0.05). Visual analog scale pain scores on movement were significantly lower in Group 1 patients (P < 0.05). We conclude that during a continuous three-in-one block, the threaded catheter rarely reached the lumbar plexus. The quality of sensory and motor blockade and initial pain relief depend on the location of the catheter tip under the fascia iliaca. IMPLICATIONS: The course of a continuous three-in-one block catheter is unpredictable. Only 23% of the catheters lie near the lumbar plexus. The success of sensory and motor blocks, as well as postoperative analgesia, depend on the position of the catheter under the fascia iliaca.

Anesthetics, Local↗

PubMed2005

Anatomical landmarks for the lumbar plexus on the posterior abdominal wall.

OBJECT: Reports describing surgical landmarks with which to identify the branches of the lumbar plexus found on the posterior abdominal wall are lacking in the English-language literature. METHODS: The authors examined 22 sides from six female and five male cadavers. Measurements were made between the branches of the lumbar plexus and various bone landmarks such as the midline vertebral bodies, supracristal plane--a horizontal line connecting the superior-most aspect of the left and right iliac crests approximating the LA-5 vertebrae--and anterior superior iliac spine (ASIS). The mean distances from the midline and as they emerged through or lateral to the psoas major muscle to the subcostal, iliohypogastric, ilioinguinal, lateral femoral cutaneous, genitofemoral, and femoral nerves, were 5.5, 6, 6.5, 6, 4.5, and 4.5 cm, respectively. At a vertical line through the midpoint between the ASIS and the midline, the subcostal, iliohypogastric, and ilioinguinal nerves were superior to the supracristal plane at mean distances of 8, 4, and 5 cm, respectively. Inferior to the supracristal plane and in a vertical line through a midpoint between the ASIS and the midline, the lateral femoral and femoral nerves were found to have mean distances of 5 and 5.5 cm, respectively. The obturator nerve had a mean distance of 3 cm lateral to the midline. Additionally, the lateral femoral cutaneous nerve had a mean distance of 1.5 cm inferomedial to the ASIS. CONCLUSIONS: A good working knowledge of the locations and anatomy of the nerves of the lumbar plexus on the posterior abdominal wall is necessary for the surgeon who operates in this region. The measurements provided herein will aid the surgeon who wishes to expose or avoid these nerves, thus precluding injury.

Abdominal Wall↗

PubMed2002

Percutaneous arterial interventional treatment of exercise-induced neurogenic intermittent claudication due to ischaemia of the lumbosacral plexus.

Radiological interventional therapy is described in seven patients with a distinct clinical syndrome of exercise-induced neurogenic intermittent claudication due to a reversible ischaemia of the lumbosacral plexus during walking accompanied by transient neurologic deficits. This condition was presumably caused by a reversible vascular steal phenomenon during exertion. The underlying vascular conditions were stenoses of the internal and/or common iliac arteries. All patients underwent percutaneous transluminal angioplasty (PTA) during the period from 1988 to 2001; an additional stent was placed in two patients. After a mean follow-up period of 18 months, four patients were asymptomatic, two had an improvement in walking-distance of 300 m and 800 m, respectively, and one patient developed a peripheral intermittent claudication without neurological complaints. In four patients, however, a further intervention was required. In patients with intermittent claudication due to exercise induced ischaemia of the lumbosacral plexus, a successful treatment is possible by means of PTA. Repeat intervention is justified if symptoms recur.

Aged↗

PubMed1995

The posterior thigh fasciocutaneous flap: vascular anatomy and clinical application.

Ten adult cadavers were used to accurately detail the vascular anatomy of posterior thigh skin. Fourteen posterior thigh specimens were dissected after blue latex injection of the internal and external iliac arteries. Six posterior thigh specimens underwent selective dye injection of individual profunda perforating arteries and the inferior gluteal artery. The findings reveal an extensive fascial plexus nourished primarily by fasciocutaneous branches of the first and second profunda perforating arteries and secondarily by a terminal fasciocutaneous branch of the inferior gluteal artery. From 1989 to 1992, 24 posterior thigh fasciocutaneous flaps were performed in 24 patients. There were 5 early postoperative complications (21 percent). All but one patient went on to satisfactory healing and stable wound coverage. Three posterior thigh fasciocutaneous flaps were used successfully despite ligation of their inferior gluteal artery blood supply in a previous surgical procedure. These anatomic and clinical findings confirm the reliability of a posterior thigh fasciocutaneous flap based primarily on the first and second profunda perforating arteries. The posterior thigh fasciocutaneous flap can survive in the absence of a patent inferior gluteal artery. Knowledge of the vascular anatomy extends the clinical applicability of the posterior thigh fasciocutaneous flap to patients who might otherwise be excluded because of prior injury or operative procedure.

Adult↗

PubMed2006

[An anatomical study on lateral ligaments of rectum].

OBJECTIVE: To identify the location and contents of the rectal lateral ligaments and its relationship with the middle rectal artery and pelvic plexus. METHODS: Twenty-nine pelvics of human cadavers were sagittally sectioned into 58 hemipelvic specimens. All of hemipelvics were dissected with sharp technique under direct vision by one surgeon. The lateral ligaments were identified and the distances from the center of its pelvic attachment to sacral promontory and coccyx were measured. Then, the lateral ligaments were transected for histologic examination. RESULTS: Lateral ligaments of rectum were found in all 58 hemipelvics. The lateral ligaments connected the posterolateral aspect of the middle 1/3 of the rectum and mesorectum to the lateral aspect of the bodies of the second, third and fourth sacral vertebrae. The distance from the lateral ligament to sacral promontory was (8.3 +/- 1.6) cm on the right side and (8.4 +/- 1.4) cm on left side. The width of lateral ligaments was (3.2 +/- 0.4) cm on the right side and (3.1 +/- 0.4) cm on the left side. The distances from lateral ligament to the coccyx on the right and left sides were (5.2 +/- 1.4) cm and (5.0 +/- 1.3) cm respectively. The content of the lateral ligaments consisted of loose connective tissue with clusters of small nerves and blood vessels. Middle rectal artery was found in 83% (48/58) of hemipelvics and 47% (27/58) of the middle rectal artery went through the lateral ligaments. The inferior hypogastric nerve plexuses were formed inside the lateral ligament, and separated the ligament into two parts. The lateral segment of the lateral ligament contained the tributaries of internal iliac artery, and the medial segment contained nerve fibers or branches to the rectum, together with the middle rectal artery. CONCLUSION: The lateral ligaments of rectum are located on the posterolateral side of the rectum, much closer to the coccyx than to the sacral promontory, consisting of connective tissue containing multiple small nerves and middle rectal artery. The lateral ligament is a pathway of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes.

Adult↗

PubMed1998

LC-DC plating with bone graft in posttraumatic nonunions in the middle third of the clavicle.

Nonunions and malunions of the clavicle are uncommon but can be disabling, causing pain, limitation of shoulder motion or local brachial plexus compression. Reconstructive procedures are focused on gaining union and restoring functional clavicular anatomy. We would like to present a surgical procedure in which an autologous iliac crest graft and a 3.5 mm low contact-dynamic compression plate (LC-DCP) are used to regain clavicular stability and union. Surgery was performed in all eight patients for symptomatic nonunion. Eight patients treated by this method between 1991-1996 showed clinical and radiological union after an average follow-up time of eight months. All patients were highly satisfied with the surgical result. The advantages of the LC-DCP in the internal fixation of clavicular nonunions with its demanding anatomical and biomechanical characteristics are presented.

Adult↗

PubMed1988

Thoracic outlet syndrome with congenital pseudarthrosis of the clavicle: treatment by brachial plexus decompression, plate fixation and bone grafting.

Although a number of cases of congenital pseudarthrosis of the clavicle have been described in the literature, they provide little direction for the treatment of this condition when it is associated with thoracic outlet syndrome. The authors describe their experience with such a case in a 20-year-old woman. Symptoms of pain in the ulnar distribution of the right forearm and discoloration of the hand with abduction of the extremity had developed over 3 years. The radial pulse was obliterated by abduction of the arm. Exploration of the brachial plexus revealed a constricting band arising from the distal fragment of the clavicle running to the first rib which, together with the mass of the pseudarthrosis, comprised the thoracic outlet. The patient was successfully treated by division of the fibrous band, reduction of the clavicle, internal fixation with a plate and iliac crest bone grafting. At follow-up the patient had a full range of motion in the shoulder and was asymptomatic.

Adult↗

PubMed2003

Presacral arteriovenous fistula: case report.

OBJECTIVE AND IMPORTANCE: We describe a case of arteriovenous fistula in front of the sacrum. Drainage induced epidural venous dilation in the sacral spinal canal. The fistula was embolized endoarterially with n-butyl-2-cyanoacrylate via its iliac arterial feeders. In follow-up digital subtraction angiography 1 month later, the fistula was found to be totally closed. The patient was followed up clinically for 2.5 years. She has remained symptom-free. CLINICAL PRESENTATION: A previously healthy 43-year-old woman presented with severe gluteal and perineal pain and a local sensation of hyperesthesia. The primary computed tomographic scan of the lumbosacral spine was normal, and emergency laparoscopy showed no signs of any pathological lesions. Magnetic resonance imaging discovered an unidentified mass in the sacral spinal canal, and the patient was hospitalized for neurosurgery. However, surgery on this mass had to be discontinued because of profuse bleeding, and the patient was referred for angiography. INTERVENTION: Diagnostic catheter angiography revealed a high-flow arteriovenous fistula anterior to the sacrum, and the mass detected earlier by magnetic resonance imaging seemed to be a dilated epidural vein draining the fistula. The feeders of the fistula originated in both internal iliac arteries, and the fistula was occluded via these arteries in two angiographic sessions. CONCLUSION: A paraspinal arteriovenous fistula may have venous drainage through the epidural venous plexus, and the ectatic veins may induce radicular symptomology. To the best of our knowledge, a paraspinal fistula at such a presacral location has not been documented previously. An unidentified mass in the sacral spinal canal should be suspected of being a dilated vascular structure. Prompt angiographic examinations with an option for embolization should be performed, and open surgical intervention should be avoided.

Adult↗

PubMed1991

[Contribution of the CT to a special technique of percutaneous lumbar anesthetic block].

The authors suggest the use of CT for the positioning of a permanent catheter, suitable for lumbar anesthetic block in painful lower limbs syndromes. This technique was employed on 12 patients suffering from vascular diseases of the lower limbs. CT allowed a good visualization of both bone structures and soft tissues, which are essential landmarks for catheter positioning. The catheter was inserted with its anterior end fixed to the anterior abdominal wall, which allowed the patient to manage its own treatment. In all cases we obtained marked symptoms regression, after 5 months of treatment. No such complications were observed as those report in literature. The main contraindication appeared to be the aneurysmatic dilatation of both aorta and iliac arteries.

Female↗