Pudendal nerve palsy complicating intramedullary nailing of the femur

A prospective study of 106 patients who had static interlocking nailing of the shaft of the femur was performed to determine the relationship between the duration and magnitude of intraoperative traction and the development of a pudendal nerve palsy. A strain-gauge, mounted in the countertraction post, measured the magnitude of the perineal pressure over time. All nailings were performed with the patient in the supine position. Postoperatively, the patients were interviewed by one of us, who had been blinded from the results of the recordings of intraoperative pressure, for a history of erectile dysfunction and changes in labial, scrotal, or penile sensation. A light-touch sensory examination of the genitalia was performed on all patients. Ten patients (six men and four women) had a pudendal nerve palsy: nine had sensory changes only, and one complained of erectile dysfunction. The symptoms had resolved at the three-month follow-up evaluation in all patients except one man who complained of dysesthesia six months postoperatively. The patients in whom a palsy did not develop had been positioned on the fracture-table and the perineal post for an average of 2.6 hours (range, 1.4 to 5.2 hours) compared with an average of 2.8 hours (range, 2.0 to 4.3 hours) for those in whom a palsy did not develop (p = 0.15). The magnitude of the total traction forces averaged 34.9 kilogram-hours for the patients who did not have a palsy compared with 73.3 kilogram-hours for those who did (p < 0.03). Adduction of the hip, as well as manipulations for reduction of the fracture, significantly increased the traction forces.(ABSTRACT TRUNCATED AT 250 WORDS)

Obstetrical lumbosacral plexus injury

Injuries to the lumbosacral plexus during labor and delivery have been reported in the literature for years, but have lacked electrophysiologic testing to substantiate the location of the nerve injury. We report 2 cases with comprehensive electrophysiologic testing which localizes the site of this obstetrical paralysis to the lumbosacral trunk (L4-5) and S-1 root where they join and pass over the pelvic rim. The paralysis may be mild or severe. Small maternal size, a large fetus, midforceps rotation, and fetal malposition may place the mother at risk for this nerve injury.

Pitfalls of pedicle screw fixation in the sacrum. A cadaver model

Five male cadavers were used to evaluate anatomically structures at risk using sacral pedicle screw fixation. Risk was defined as the likelihood of penetration by K-wires placed through the pedicles and cortices at the S1, S2, and S3 levels. A scale based on the distance from the wire to the vital structure was developed to quantify risk. Instrument insertion techniques were classified as direct and lateral. The direct technique at S1 placed the left common iliac vein and the sympathetic chain at high risk. The sympathetic chain was also at high risk at the S2 and S3 levels. The lateral technique placed the lumbosacral trunk at high risk at the S1 level, as well as the S1 nerve root with screw placement at the S2 level. Anterior cortical penetration during sacral pedicle screw fixation places anatomic structures at variable risk depending on the technique used.

[Acute plexus lesions in heroin dependence]

A wide spectrum of acute and chronic neurological syndromes are associated with heroin addiction. We report two cases with acute brachial/lumbar plexus lesions, with details of the clinical findings, diagnostic procedures and therapy. Possible causes are allergic or toxic reactions to heroin or added substances, as well as nerve compression due to local muscle swelling in connection with rhabdomyolysis. The extent of paresis which occurs is also determined by this compression.

Anatomic consideration for sacral screw placement

Instrumentation of the lumbosacral spine increasingly involves screw fixation to the sacrum. Recommended locations and techniques for screw placement vary, particularly when bicortical purchase of the sacrum is performed. The purpose of this study was to describe the critical anatomy and potential injuries to neurovascular and visceral structures anterior to the sacrum. Lack of awareness can lead to life-threatening complications. The study included 22 fresh human cadavers with no prior spinal surgery. Specimens were placed in a prone position, and the lumbosacral spine was exposed. Two 6.5-mm screws were inserted using one of two techniques, respectively: Starting just inferior to the S1 facet one screw was angled 25 degrees caudally and 30 degrees laterally; in the second technique, lateral inclination was increased to 45 degrees. In addition, all specimens had screws placed in the S2 pedicles. An anterior dissection was performed to allow evaluation of the neurovascular and visceral structures at risk for injury by, or adjacent to, the screw tips. All significant neurovascular structures in the area of concern were constant in position. The internal iliac vein and the lumbosacral nerve trunk were most at risk for injury by the 30 and 45 degrees laterally directed screws. The sigmoid colon, though close to the S2 screw, was protected by its mesentery. Screws placed in the S1 pedicle were least likely to injure the neurovascular bundle. A lateral and a midline safe zone were identified.

[Rhabdomyolysis and a plexus lesion following heroin poisoning]

We report about a young female patient who suffered a rhabdomyolysis and a plexus lesion after heroin intoxication. A computer-tomography was made to reveal the extent of myonecrosis. A larger rhabdomyolysis of muscles of the pelvis and left thigh was seen. A residual paresis of the left N. peronaeus existed at discharge of the patient.

Neurologic deficits associated with sacral wing fractures

Twelve of 96 patients with pelvic fractures suffered neurologic deficits. Four secondary to acetabular fractures were excluded from the study. Of the remaining eight, five were found by CT scan to be secondary to fractures of the sacral wing extending through the sacral foramina. On the basis of this study, it is believed that the neurologic injuries were due to sacral root injuries rather than lumbosacral plexus injuries. This concept potentially could lead to surgical approaches for decompression of sacral root trauma.

[Intracavernous pharmacotherapy in men who have undergone cystectomy for neoplasia]

Impotentia erigendi is a consequence of radical surgery such as cystectomy due to neoplasia. It is caused by damage to neurovascular structures, and in particular to the nerve fibres of the sacral plexus. Current therapies include the use of penile prostheses or drug therapy. The paper reports the Authors' personal experience of the use of intracavernous drug therapy in 24 patients cystectomised due to vesical carcinoma. Objectively valid results were obtained in 33% of patients. No complications were observed and the treatment represents a valid alternative to mechanical prosthesis.

[Early complex treatment of fractures of leg bones and peripheral nerve injuries]

A retrospective analysis of results of treatment of 104 patients with fractures of long tubular bones associated with injuries of peripheral nerves has shown complex therapy to be necessary. Main components of this treatment were biogenic stimulators, vitamin B12, spasmolytic and dehydration drugs in combination with electrophoresis with potassium iodide and thermal procedures. Rapid disturbance of conductivity of nerve trunks after trauma should be followed by revision of the given segment of the extremity in order to remove hematoma and make reposition of displaced fragments of the bone, which can provide recovery of the disturbed function of the nerve.

External iliac artery and lumbosacral plexus injury secondary to an open book fracture of the pelvis: report of a case

Lumbosacral plexus or external iliac artery injuries associated with pelvic fracture are reported rarely in the literature. A case involving a noncompound open book pelvic injury with diastasis of the symphysis pubis and combined ipsilateral lumbosacral plexus and external iliac artery injury is reported. Repeated clinical examination to diagnose vascular lesions with evolving pulse deficits is emphasized.

Lumbosacral plexopathy following regional paracervical block anaesthesia

We report a 35 year old lady who developed lumbosacral plexopathy immediately following regional paracervical block anaesthesia for medical termination of pregnancy. There was only partial recovery at one year. The neurological deficit and its mechanisms are discussed.

Acute lumbosacral plexopathy in diabetic women after renal transplantation

Renal transplantation is an accepted treatment for patients with end stage renal disease from insulin-dependent diabetes mellitus. Acute lumbosacral plexopathy developed following renal transplantation in 4 female patients with insulin-dependent diabetes mellitus between January 1, 1981 and June 30, 1988. In all 4 patients the internal iliac artery was used for revascularization of the renal allograft with ligation of the anterior and posterior divisions. Within 24 hours of surgery they complained of ipsilateral buttock pain, numbness in the leg and weakness below the knee. This complication has not been observed in nondiabetic patients at our institution, nor in diabetic patients when the internal iliac artery was not used. However, lumbosacral plexopathy occurred in 4 of 27 (14.8%) female patients with insulin-dependent diabetes mellitus when the internal iliac artery was used (p less than 0.001). Age, duration of insulin-dependent diabetes mellitus, hypertension, cigarette smoking history and kidney donor were not significant predictors of this complication. This unusual and newly recognized complication appears to result from ischemia of the lumbosacral plexus following ligation of the internal iliac artery in patients with severe small vessel disease.

Diagnosis and treatment of genitofemoral and ilioinguinal neuralgia

During the past 8 years, a total of 36 patients were diagnosed as having either ilioinguinal or genitofemoral neuralgia. A multidisciplinary approach (surgeon, neurologist, anesthesiologist) as well as local blocks of the ilioinguinal nerve or paravertebral blocks of L1,2 were essential to determine which nerve was likely to be entraped. Seventeen of the 19 patients having a diagnosis of ilioinguinal neuralgia after previous inguinal herniorraphy were completely free of pain after resection of the entrapped portion of the nerve. Seventeen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorraphy, blunt abdominal trauma, or another operation. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 12 of 17 of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of operations in the inguinal region. When the diagnosis is made by a multidisciplinary approach, neurectomy is frequently successful in relieving severe pain and paresthesias without serious morbidity.

A prospective study of peripheral nerve lesions occurring in traumatic brain-injured patients

The purpose of this study was to determine the frequency and severity of peripheral nerve lesions occurring in patients with traumatic brain injury. A prospective study of 132 patients was conducted. Patients fulfilling research criteria (flaccidity, areflexia, abnormal motor patterns) underwent neurodiagnostic examination. Fifteen electromyograph/NCV studies were performed, yielding positive findings in 13 patients (10%); 3 patients were found to have preventable lesions. Many patients had permanent impairment or attendant complications from the peripheral nerve injury that adversely affected eventual recovery.

[Characteristics of rehabilitation treatment after tendon and muscle plastic surgery in children with sequelae of injuries of the peripheral nerves]

The authors analyse the treatment of 153 children aged 4.5-15 who were performed 213 tendon- and myoplasties for persistent lesions of the peripheral nerves. The peculiarities of rehabilitative therapy in this category of patients are described. Three groups of muscles used for grafting and requiring special approach during the rehabilitation period have been distinguished. The rehabilitative treatment is divided into three periods: preoperative preparation, working out of the new function and securing of the new motor act. The peculiarities of the rehabilitative treatment in each period have been substantiated.

Electromyographic abnormalities in neurologic injury associated with pelvic fracture: case reports and literature review

The incidence of neurologic injury associated with pelvic fractures is estimated at 10%. Studies have demonstrated that patients with double vertical pelvic fractures (combined injury to the anterior third of the pelvic ring and the sacroiliac area) are most at risk, with a 46% incidence of neurologic injury. Patients with pelvic fractures usually have many other associated injuries and medical complications, making the patients' neurologic deficits difficult to assess and thus easy to overlook in the acute setting. Three such patients are described. Electromyography was useful in confirming their diagnoses, thus allowing appropriate management.

Effects of cisapride on constipation due to a neurological lesion

Two patients with intractable constipation and an atonic bladder due to a partial spinal cord lesion and sacral nerve lesion are described. Treatment with cisapride (4 x 10 mg daily) was undertaken. After a few days the stool passed spontaneously. The effect was dose-dependent and has been maintained for at least 40 months. Normal bladder function was not achieved.

Lumbosacral plexus avulsion injury: clinical, myelographic and computerized tomographic features

A rare case of lumbosacral plexus avulsion studied with computerized tomography (CT) in a 5-year old Saudi involved in a vehicular accident with resultant left lower limb monoparesis is presented. Myelography and CT were superior to electromyographic findings in this case. Such cases should be closely followed and surgical exploration and decompression offered if any evidence of cauda equina compression develops.

Lumbosacral plexus lesions: correlation of clinical signs and computed tomography

Neurological signs and computed tomographic morphology were compared in 60 patients. The primary neurological deficit was most commonly located in the sacral (n = 31) or lumbar plexus (n = 23) and was most commonly caused by a neoplasm (n = 40). In 78% of the patients it correlated with the lesions detected by computed tomography (CT). CT reliably demonstrates extraspinal mass lesions, but only moderately well predicts functional signs.

[Post-traumatic L5-S1 root avulsion. Myelographic and x-ray computed tomographic study. Apropos of a case. Review of the literature]

A patient presented an avulsion of left L5-S1 roots, with S1 meningocele, following a road accident. Saccoradiculography and CT scan imaging, even without contrast, allowed identification of total lesion in a suggestive clinical context. The characters of the CT scan images are emphasized. Images showed also the presence of pseudo-meningoceles and absence of roots.

Gastric partitioning complicated by peripheral neuropathy with lumbosacral plexopathy

Gastric bypass and partitioning are the two surgical procedures most commonly used in the treatment of morbid obesity. They are, however, not without their postoperative complications. These include acute and chronic problems such as wound infection, gastric leak, obstruction, embolism, and neurologic sequelae. Many studies have mentioned the frequent occurrence of polyneuropathy in the postgastrectomy state. This report describes a 38-year-old patient who developed an asymmetric peripheral neuropathy with lumbosacral plexus involvement following gastric bypass surgery for morbid obesity.

[Modern technics for studying injuries of the lumbo-ischiatic plexus. Apropos of a new case]

A 22 year old patient was admitted with multiple lumbosacral root meningoceles following a motorbike accident. Because of the marked neurologic deficit in left lower limb a radiculographic exploration was completed by a CT scan, with improvement in analysis of images, post-traumatic pseudo-meningoceles being neither an absolute proof nor the unique lesion responsible for the clinical picture. They may be missing whereas the root is absent. Combining these two examinations provides for total screening of lesions and more selective choice of therapy.