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We present an alternative imaging technique for evaluation of the sacral plexus and sciatic nerve. Images were obtained in the oblique coronal, oblique sagittal, and oblique axial planes using the piriformis muscle as the initial reference point. Evaluation of the sciatic nerve is optimized by the multiplanar capability of MRI.
Studies of the sacral plexus have been made in six cadavers to demonstrate the increased tension due to medial hip rotation. A standard protocol was adopted for the straight-leg-raising test (SLR) and three qualifying tests--dorsiflexion of the ankle, medial hip rotation, and cervical flexion--when examining 442 patients. Positive signs on medial hip rotation were frequently associated with evidence of increased tension and neurologic dysfunction of lumbosacral roots. It is concluded that uncontrolled hip rotation reduces the value of the SLR is a useful qualifying test for increased root tension, and that the diagnostic value and repeatability of SLR would be improved by adopting a standardized protocol.
The objective of this prospective 18-month study was to evaluate the clinical and laboratory effects of repeated intrathecal injections of chemotherapy in children with acute leukemia. All procedures were performed under general anesthesia, and complications were prospectively recorded. Laboratory measurements included lumbar puncture opening pressure, cerebrospinal fluid (CSF) chemistry, and cell count and morphology. Central venous pressure and ophthalmologic examinations were also performed. Forty-seven children underwent 247 intrathecal injections of chemotherapy. Adverse effects (13.7% of the procedures) included nausea and vomiting, back pain, and headache. One child each had transient cauda equina syndrome, transient communicating hydrocephalus, and persistent sacral plexus injury. The mean lumbar puncture opening pressure was significantly higher after intrathecal therapy than before (22 +/- 8 vs. 15 +/- 9 cm H2O, P = 0.02) and higher than reported in age-matched children without leukemia. All CSF chemistries, cell count, and morphology were normal. The overall incidence of complications was 13.7%. Most were mild and resolved quickly, but significant neurologic complications did occur. Lumbar puncture opening pressure was significantly higher in children with acute leukemia after intrathecal chemotherapy.
Persistent low back pain in children demands thorough investigation. An unusual cause of such discomfort is hematocolpos secondary to imperforate hymen in premenarchal girls. Experience with four patients whose initial primary symptom was low back pain has been documented. All had large pelvic masses with greater than 400 ml of old blood being drained at hymenotomy in all patients. Irritation of the sacral plexus or nerve roots is postulated as a mechanism for the referred back pain. Hematocolpos should be included in the differential diagnosis of prepubertal girls who have low back pain.
Unexpected spinal anesthesia, occurring after peripheral nerve blocks close to the spine, may be caused by a centripetal spread of the local anesthetic along the injected nerve to the spinal cord. In order to analyze the pathway of such a spread, a radioactive local anesthetic mixed with a fluorescent dye was injected into difrerent compartments of the rabbit sciatic nerve, and the early distribution of these tracers was studied by scintillation counting and fluorescence microscopy. Epineurial (extrafascicular) injections were of low injection pressure (25-60 mmHg) (3.3-7.9 kPa) and limited spread, while endoneurial (intrafascicular) injections reached higher pressures (300-750 mmHg) (39.9-99.7 kPa) and caused a rapid spread over long distances within the fascicle. The sacral plexus seemed difficult to pass. However, 20% of endoneurial injections reached the spinal cord, where the injectate primarily spread in the thin subpial space. Our experimental findings suggest that intraneural injections of local anesthetics are responsible for the reported cases of unexpected spinal anesthesia due to inadvertent intrafascicular spread. Although intrafascicular injections are rarely made, we recommend that intraneural injections of local anesthetics or other solutions close to the spine should be avoided, as they may cause unexpected spinal anesthesia or lesion of the cord.
"Dry ejaculation" occurred in none of 15 patients with testicular cancer treated by right-sided retroperitoneal lymph node dissection (RLND). After left-sided and bilateral RLND, "dry ejaculation" was observed in 7/21 and 51/61 men respectively. Twelve of 21 patients with "dry ejaculation" or small volumes of seminal fluid had true retrograde ejaculation. In 7 of 10 men the ejaculatory volume increased significantly after treatment with imipramine chloride. Four men impregnated their wives during treatment with the drug. Without impairing the results of therapy it is possible to spare fibres from the sympathetic chains and pre-sacral plexus during RLND due to testicular cancer, thus preserving fertility in at least 40% of patients.
A new surgical method was introduced for the treatment of Ib lymph node positive and IIb cervical cancer patients. The lateral resection plane corresponds to the true pelvic side wall, the plane represented by the internal obturator muscle, the linea arcuata, and the piriformis muscle with the convergent branches of the sacral plexus. The LEP procedure overcomes the limitations of the standard class III-IV radical hysterectomy, which leaves in situ the gluteal superior, inferior and pudendal nodes, thus improving local control and survival.
The clinical data of 59 patients with hemophilia A or B are reviewed. Intracranial bleeding was observed in 6 patients and a minor bleeding episode was assumed in a further 8 patients. Neurosurgical evacuation of the hematoma was necessary in 2 cases and the remaining patients were treated solely with factor VIII or IX. In 10 patients a peripheral nerve lesion was observed, paresis of the femoral nerve being the most frequent (5 cases). Two patients showed a lesion of the lumbar and sacral plexus, 2 patients a lesion of the radial nerve and one patient a lesion of the cutaneous femoris lateralis nerve.
Cortisol was found in myelinated nerve fibers of the lumbo-sacral plexus (2.0 to 6.0 microg per gram of tissue) and in the sympathetic chain with dorsal root ganglia (0.2 to 0.4 microg per gram of tissue).
A computed tomographic (CT) guided transgluteal approach through the greater sciatic foramen was used to drain pelvic abscesses and fluid collections in 21 patients. Ideal catheter placement should traverse the lower portion of the greater sciatic foramen at the level of the sacrospinous ligament. This avoids the vascular and neural elements that are located slightly cephalad at the level of the piriformis muscle. Percutaneous drainage through this approach was successful in avoiding surgery in 17 patients (81%). Pain was the most common complication and was generally associated with a more cephalad approach, transgressing the piriformis and the sacral plexus. CT-guided percutaneous drainage of pelvic abscesses through the greater sciatic foramen should be used when the more standard transperitoneal approach is not possible.
We report on a rare peripartal neuropathy of the leg caused by pro longed difficult labor in which forceps were used or caesarean sec tion was performed. Immediately after delivery, the 2 patients corn plained of a unilateral footdrop and numbness in the leg. The foot drop was most likely due to a compression of the lumbosacral trunl exposed to the fetal head. This trunk contains fibres from the lumba roots L4 and L5 and connects the lumbar with the sacral plexus. The outcome was favourable in both patients. If subsequent pregnancies occur, caesarean section may be indicated.
Priapism caused by an inflammatory process is rare. We report on a 25-year-old man with priapism due to an infiltration in the pelvic region, enclosing the right sacral plexus. Blood cultures revealed Staphylococcus aureus to be the causal organism. Treatment consisted of parenteral antibiotics, aspiration of the corpora cavernosa and injection of epinephrine, resulting in a flaccid penis and full recovery of potency after 3 weeks. A literature review was conducted for infection and inflammatory processes as a cause for priapism.
A left persistent primitive sciatic artery was observed in a Japanese male cadaver. The sciatic artery arose from the internal iliac artery and perforated the ventral division of the sacral plexus. The sciatic artery did not anastomose with the perforating arteries nor the popliteal artery. The left femoral artery was incompletely developed, attenuating and terminating as the saphenous artery. Instead of the femoral artery, direct continuation of the profunda femoris artery, which probably corresponded to the fourth perforating artery, became the popliteal artery. Other vessel anomalies were observed in various regions. They included; (1) the retroesophageal right subclavian artery; (2) the left vertebral artery entering the transverse foramen of the 4th cervical vertebra; (3) bilateral occurrence of the superficial brachial artery; (4) the left gastric artery independently arising from the abdominal aorta; (5) a hepatolienomesenteric trunk; (6) three accessory renal arteries; (7) double testicular arteries; (8) the arteria intermesenterica; (9) a venous ring termed the 'renal collar', and (10) paired thoracic ducts. The present cadaver was considered to be a very rare case in which many primitive vascular systems had extensively persisted in various parts of the body.
SSEPs produced in response to PTN stimulation were studied in 41 normal infants and children from 4 months to 16 years in age. SSEPs were recorded on the scalp with reference electrodes attached to the contralateral knee, shoulder and earlobe. Four positive SSEPs, PI, PII, PIII and PIV, named in order of appearance, and one negative SSEP, N0, were recorded as FFPs on the scalp with the cKn reference. Following these FFPs, the cortical component P1 which corresponded to P37 in adults was recorded. Preceding P1, another negative wave, N1, could be recognized solely at Cz' mainly at the onset of P1. P1 and N1 could be identified in all children with derivations with noncephalic references, although they could not be identified in 5 of 41 children with a Cz' - Fpz derivation. PI, bilobed in configuration, was considered to originate at the sacral plexus or entry to the spinal canal. PII was the least reproducible potential and was considered to originate at the dorsal root, dorsal horn or conus medullaris. PIII, PIV and N0 were considered to originate at the cervical cord, brain stem and thalamus, respectively. With the peak latencies of PI, PII, PIII, PIV, N0, N1 and P1, the RV was calculated in order to eliminate the influence of body height. The RV of the later appearing components leveled off in the older age categories. The RV of P1 reached a steady level at 3 years of age. RVs of PII and PIII appeared to level off by the age of 6 years. The RV of PIV leveled off by the age of 9 years. RVs of N0 and N1 leveled off by the age of 12 years, and that of P1 decreased until over 12 years of age. Furthermore, to eliminate the influence of naturation in the peripheral nerves, the RV was obtained from PI-PIV, PI-P1, PIV-P1 and N1-P1 interpeak latencies. The RVs of these 4 interpeak latencies all decreased until over 12 years of age. Accordingly, the maturation of afferent conduction in the central nervous system after PTN stimulation appeared to be complete after 12 years of age.
In 21 normal subjects, far-field somatosensory potentials were recorded from the scalp after stimulation of the tibial nerve at the ankle (tibial SEP). With the use of a knee reference contralateral to the side of stimulation, the tibial SEP consisted of three major positive peaks, P17, P24, and P31, and three additional but inconsistent components, P11, P21, and P27. Presumable generator sources of the tibial SEP are the popliteal fossa for P11, entry to the sacral plexus for P17, the cauda equina for P21, entry to the conus medullaris for P24, the rostral spinal cord for P27, and the brainstem for P31.
OBJECTIVE: The authors examined the incidence and radiologic characteristics of plexiform neurofibromas in neurofibromatosis-1 (NF-1) to define a cohort at greatest risk for malignant nerve-sheath tumors. BACKGROUND: Plexiform neurofibromas are a frequent complication of NF-1. They can impair function, produce disfigurement, and be the site for the development of malignant nerve-sheath tumors. The incidence and natural history of plexiform neurofibromas is unknown. METHODS: CT imaging of the chest, abdomen, and pelvis was performed in 91 of 125 consecutive adults (age, > or = 16 years) with NF-1. RESULTS: Twenty percent of patients had plexiform neurofibromas of the chest in the paraspinal, mediastinal, or supraclavicular area. Approximately 40% of patients had abnormal abdominal/pelvic scans. The paraspinal, sacral plexus, sciatic notch, and perirectal regions were the most common sites. Most plexiform neurofibromas were asymptomatic. Imaging also revealed a number of tumors, including malignant nerve-sheath tumors, adrenal tumors, carcinoids, and schwannomas. CONCLUSIONS: The frequency of plexiform lesions and other tumors in NF-1 indicates that clinicians should monitor young adults carefully; however, imaging characteristics alone cannot reliably distinguish benign from malignant lesions.
UNLABELLED: Parasacral sciatic blockade results in anesthesia of the entire sacral plexus. In this study we sought to determine the spread of the local anesthetic injected through a parasacral catheter, the anatomical location of the inserted catheters, and the extent and reliability of the blockade. In this study, 87 consecutive patients undergoing major lower limb surgery were enrolled. After placement of the catheter and injection of 8 mL of radio-opaque contrast dye, radiographic images were evaluated for dispersion of the injectate. Sensory and motor evaluations were also performed. Radiographic analysis of the injectates revealed that nearly all catheters (86 catheters, 99%) were in the correct anatomical position. The mean volume of local anesthetic injection was 21 +/- 3 mL. All patients developed a full sensory block of all three major components of the sciatic plexus (tibial, common peroneal, and posterior cutaneous nerve of the thigh). We conclude that the parasacral sciatic block results in frequent success of blockade of all three major components of the sciatic plexus and it has a small risk of complications. Contrast radiography can be used to document the catheter placement. IMPLICATIONS: The parasacral sciatic block results in a frequent success rate of blockade of all three major components of the sciatic plexus (tibial, common peroneal, and cutaneous nerve of thigh). A contrast radiography can be used to confirm the proper position of the catheter.
Our aim was to objectively evaluate the efficacy of obturator nerve anesthesia after a parasacral block. Patients scheduled for knee surgery had a baseline adductor strength evaluation. After a parasacral block with 30 mL 0.75% ropivacaine, sensory deficit in the sciatic distribution (temperature discrimination) and adductor strength were assessed at 5-min intervals. Patients with an incomplete sensory block (defined as a temperature discrimination score of less than 2 in the 3 cutaneous distributions of the sciatic nerve tested) 30 min after the parasacral block were excluded from the study. Subsequently, a selective obturator block was performed with 7 mL 0.75% ropivacaine and adductor strength was reassessed at 5 min intervals for 15 min. Finally, a femoral block was performed using 10 mL 0.75% ropivacaine. Patient discomfort level during each block was assessed using a visual analog scale (VAS). Thirty-one patients completed the study. Five patients were excluded as a result of inadequate sensory block in the sciatic distribution 30 min after the parasacral block (success rate of 89%). Thirty min after the parasacral block, adductor strength decreased by 11.3% +/- 7% compared with baseline (85 +/- 24 versus 97 +/- 28 mm Hg, P = 0.002). Fifteen min after the obturator nerve block, adductor muscle strength decreased by an additional 69% +/- 7% (16.6 +/- 15 versus 85 +/- 24 mm Hg, P < 0.0001). VAS scores were similar for all blocks (26 +/- 19, 28 +/- 24, and 27 +/- 19 mm for parasacral, obturator, and femoral respectively). Four parasacral blocks were simulated in 2 fresh cadavers using 30 mL of colored latex solution. The spread of the die in relation to the obturator nerve was assessed. Injection of 30 mL colored latex into cadavers resulted in spread of the injectate restricted to the sacral plexus. These findings demonstrate the unreliability of parasacral block to achieve anesthesia of the obturator nerve. A selective obturator block should be considered in the clinical setting when this is desirable.