Spinal and pudendal nerve modulation of human corticoanal motor pathways

We investigated the effects of lumbosacral and pudendal nerve stimulation on the corticofugal pathways to the human external anal sphincter. In 11 healthy subjects, anal sphincter electromyographic responses, evoked to transcranial magnetic stimulation of the motor cortex, were recorded 5-500 ms after lumbosacral root or pudendal nerve stimulation. Lumbosacral and pudendal nerve stimulation alone evoked responses with amplitudes of 293 +/- 73 and 401 +/- 153 microV and latencies of 3.2 +/- 0.2 and 2.2 +/- 0.2 ms, respectively. Cortical stimulation also evoked responses with amplitudes of 351 +/- 104 microV and latencies of 20.9 +/- 1.1 ms. When lumbosacral or pudendal nerve stimulation preceded cortical stimulation, the cortically evoked responses were facilitated (P < 0.01), with the effect appearing greatest at 5-20 ms after both lumbosacral and pudendal excitation and at 50-100 ms after lumbosacral excitation alone. Our results demonstrate that cortical pathways to the external anal sphincter are facilitated by prior lumbosacral and pudendal nerve stimulation, indicating that sensorimotor interactions are important in the central neural control of sphincter function.

Electrophysiological evidence for the nomenclature of the pudendal nerve and sacral plexus in the male rat

Surgical microscopy and electrophysiological techniques were used to standardize the nomenclature for the pudendal nerve and sacral plexus according to their somatic axonal composition in the male rat. We conclude that the pudendal nerve is the segment running from the L6-S1 trunk to the sacral plexus, carrying efferent fibers to the coccygeus, internal obturator, ventral and dorsal bulbospongiosus, ischiocavernosus, external anal sphincter, and external urethral sphincter muscles, and afferent fibers from the penis, prepuce, scrotum, and ventral-proximal tail. The sacral plexus is the complex formed by the bridge-like structure connecting the pudendal nerve with the lumbosacral trunk, and two nerve branches emerging from it, one innervating the proximal half of the scrotal skin, and the other innervating the muscles at the base of the penis known as the motor branch. These branches are only considered as a part of the sacral plexus because they integrate axons from both the lumbosacral trunk and pudendal nerve. The gross anatomy of the pudendal nerve and sacral plexus has a main organization that was observed in 70% of cases, whereas the remaining 30% occurred in two variants. This nomenclature is appropriate to describe the pudendal nerve and sacral plexus in studies that involve them being lesioned or electrophysiologically analysed. A main additional finding was that two large afferent branches innervate the scrotum, one the proximal half and the other the distal half. As mentioned above, the proximal branch belongs to the sacral plexus, whereas the distal branch belongs to the pudendal nerve because all its axons travel to the cord via this nerve. Since stimulation or even manipulation of the scrotal branches resulted in the secretion of semen containing spermatozoa, it is suggested that scrotal afferents are involved in some way in the ejaculatory process, a topic that deserves further research.

Modulation of feline bladder and distal urethral responses to dorsal sacral root stimulation by intrathecal administration of a kappa 1-opioid agonist

OBJECTIVES

We examined bladder and distal urethral responses to sacral dorsal root (SDR) electrostimulation with simultaneous intrathecal administration of a kappa 1-opiate agonist.

METHODS

Experiments were conducted on 14 spinally intact and 6 chronic spinally transected decerebrated mongrel cats. In the chronically spinalized cats, midthoracic complete spinal cord transection was performed 6 to 8 weeks before the electrostimulation experiments. Sympathetic denervation was carried out by cutting the sympathetic chain and the hypogastric nerve bilaterally. Proximal ends of the cut S1-3DR were stimulated, and bladder pressure and urethral perfusion pressure changes were recorded before and after drug administration.

RESULTS

The S2DR electrostimulation in spinally intact cats produced the best vesical contraction, but with dyssynergic urethral response. The magnitude and the pattern of the response changed with the different stimulation parameters. U-50,488H, a selective kappa 1-opiate receptor agonist, decreased significantly the bladder and the urethral responses to S2DR stimulation in spinally intact but not in chronic spinally transected cats. Nor-BNI, a kappa antagonist, reversed these responses in spinally intact cats.

CONCLUSIONS

Our results showed that it is feasible to produce bladder contraction with SDR stimulation and suggest that kappa 1 receptors may have a role in bladder and distal urethral reflexes at the suprasacral level.

Delivery and pudendal nerve function

OBJECTIVE

To assess the impact of mode of delivery and the occurrence of pelvic instability upon the pudendal nerve function and relate the pudendal nerve function to the occurrence of anal and urinary incontinence.

METHODS

One hundred and forty-six pregnant women were examined during pregnancy and 12 weeks post partum with measurement of pudendal nerve terminal motor latency (PNTML), the difference between the two measurements was defined as delta PNTML. Anal and urinary continence status, details of delivery and the occurrence of pelvic instability were recorded prospectively.

RESULTS

Pudendal nerve terminal motor latency increased from 1.7 msec in primiparae and 1.8 msec in multiparae during pregnancy to 2.0 msec (p < 0.001) and 2.1 (p < 0.001) respectively after delivery. The increase was significantly higher after the use of vacuum extraction (p < 0.04). Multivariate analysis showed that delta PNTML was associated with age, the presence of pelvic instability and the use of vacuum extraction. Whereas delta PNTML was not associated with factors such as infant's head circumference and weight, parity, cesarean section, pudendal block, epidural analgesia and second stage of labor. Only four women had anal incontinence after delivery. Twenty-five women with urinary incontinence had a significantly higher mean PNTML (2.20 msec) than 121 continent women (2.01 msec).

CONCLUSION

Pudendal nerve terminal motor latency increases in both primiparous and multiparous women after delivery. In 10% of the women the increase resulted in a pathologic PNTML value > 2.4 msec. The delta PNTML was significantly associated with age, the occurrence of pelvic instability and the use of vacuum extraction. The group of women with urinary incontinence had a significant increased PNTML.

Responses of rat sacral spinal neurons to mechanical and noxious thermal stimulation of the tail

In this study we investigated the receptive field properties, responses to mechanical and thermal stimuli, and sensitivity to systemic administration of pentobarbital sodium and morphine of single neurons recorded in the sacral spinal cords of pentobarbital-anesthetized rats. Fifty-three neurons responded to innocuous mechanical stimulation of the tail. Of 45 neurons that were additionally tested with noxious thermal stimulation, 62% responded and were classified as wide-dynamic-range or multireceptive neurons. Recording sites were located mainly in the middle layers of the S2-S4 dorsal horn. Mechanosensitive receptive fields on the tail varied widely in size (range 0.14-35 cm2, mean 10.33 cm2) and form, and were in nearly all cases bilateral. Most neurons responded with a high-frequency discharge followed by a more slowly adapting response to pressure stimuli delivered with von Frey hairs. Responses (maximal frequency and total number of impulses) increased in a graded manner to pressure stimuli ranging from 1.2 to 447 g. For neurons responsive to noxious heating of the tail, responses increased in a linear manner over the range of 38-54 degrees C and often leveled off at higher temperatures. Of nine neurons tested with both graded von Frey and noxious heat stimuli, mean responses (maximal frequency and total number of impulses) evoked by the strongest pressure stimuli were larger than those evoked by the most intense heat stimuli, but the difference was not statistically significant. Responses to repeated 48 degrees C stimuli were significantly attenuated within 8 min after systemic administration of morphine (1 or 2 mg/kg ip), reaching maximal suppression (to 37.3%; N = 13) after 18 min, with recovery following systemic naloxone. After morphine (1 and 2 mg/kg ip), the slope of the population stimulus-response function for noxious heat was reduced (51.8%), and the threshold was increased (by 4 degrees C). Responses to noxious heat were significantly depressed (to a mean of 54%; N = 10) by supplemental administration of pentobarbital (mean 17 mg/kg over 5 min). On the basis of similarities between the present data and previous behavioral measures of tail flick stimulus-response functions and their modulation, it is suggested that some of the present neurons might function as interneurons in the tail flick reflex arc.

Estrogen induces axonal outgrowth in the nucleus retroambiguus-lumbosacral motoneuronal pathway in the adult female cat

In 1995, we discovered a new pathway in the cat, which originates from the nucleus retroambiguus (NRA) and terminates in a distinct set of lumbosacral hindlimb, axial, and pelvic floor motoneuronal cell groups [VanderHorst VGJM, Holstege G (1995) Caudal medullary pathways to lumbosacral motoneuronal cell groups in the cat: evidence for direct projections possibly representing the final common pathway for lordosis. J Comp Neurol 359:457-475]. The NRA is a compact group of interneurons located laterally in the caudal medulla oblongata. Its projection to lumbosacral motoneurons is thought to represent the final common pathway for male mounting and for female receptive or lordosis behavior. However, females only display lordosis behavior. However, females only display lordosis behavior when they are in estrus, which suggests that the NRA-lumbosacral pathway is only active during estrus. This raised the question of whether estrogen affects this pathway. The effect of estrogen on the NRA-lumbosacral projection was studied light microscopically, using wheat-germ agglutinin horseradish peroxidase (WGA-HRP) as a tracer. The rubrospinal pathway served as control. The density of labeled NRA fibers in their target hindlimb motoneuronal cell groups appeared abundant in estrous and very weak in nonestrous cats. Such differences were not found in the rubrospinal pathway. For electron microscopical study, the NRA projection to the semi-membranosus motoneuronal cell group was selected. In this cell group, an almost ninefold increase of labeled profiles was found in estrous versus nonestrous cats. Moreover, the semimembranous motoneuronal cell group contained labeled growth cones in estrous, but not in nonestrous, cats. The present study is the first to show that estrogen induces axonal outgrowth of a precisely identified pathway in the adult mammalian central nervous system. The possible mechanisms underlying this outgrowth are discussed.

Feasibility of implant driven micturition in paraplegic dogs

OBJECTIVE

This study evaluates the feasibility of using existing technology for implant driven micturition in paralyzed dogs (part I) and also examines a less invasive technique for implant driven micturition (part II).

STUDY DESIGN

Part I. Sacral nerve root dimensions and bladder and urethral pressure responses to intradural and extradural sacral nerve root stimulation were measured to determine the optimal location and size for sacral nerve root electrodes. Part II. Sacral nerve roots were stimulated via wire electrodes introduced into the S2 foramina.

ANIMALS OR SAMPLE POPULATION

Ten dogs (five dogs in part I and five dogs in part II).

METHODS

Part I. Microtip pressure transducers were used to monitor bladder and urethral pressure responses to sacral nerve root stimulation with tripolar hook electrodes. After euthanasia, sacral nerve root, and spinal canal dimensions were measured. Part II. Bipolar electrical stimulation of the sacral nerve roots was performed by introducing wire electrodes into the S2 foramina. Bladder and urethral pressures were recorded as in part I.

RESULTS

Part I. Stimulation of SI produced an increase in urethral, but not bladder, pressure. Stimulation of S2 or S3 produced increases in bladder pressure and decreases in urethral pressure. Intradural and extradural nerve roots were not significantly different with respect to nerve dimensions or effects on nerve stimulation. Part II. High bladder pressures were achieved, but effective voiding could not be produced, primarily because of urethral resistance.

CONCLUSIONS

Part I. Extradural implantation was determined to be the most appropriate site based on ease of dissection, nerve root dimensions, and decreased risk of iatrogenic trauma. Enough space is available to implant two to four tripolar spiral nerve cuffs. Part II. Transforaminal sacral nerve root stimulation did not effectively empty the bladder.

CLINICAL RELEVANCE

Clinical trials in paraplegic dogs are necessary to evaluate the number of sacral nerve cuff electrodes necessary to produce effective bladder emptying.

Sacral rhizotomies and electrical bladder stimulation in spinal cord injury. Part I: Clinical and urodynamic analysis. Dutch Study Group on Sacral Anterior Root Stimulation

OBJECTIVES

To present the clinical and urodynamic results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral rhizotomies and electrical bladder stimulation with the Finetech-Brindley stimulator during a 3-year inclusion and study period.

METHODS

226 patients with spinal cord lesion and urological problems due to hyperreflexia of the bladder were screened for sacral rhizotomies and electrical bladder stimulation. In 52 patients complete posterior sacral root rhizotomies were performed and a Finetech-Brindley sacral anterior root stimulator implanted. All patients were screened and followed with a standard protocol.

RESULTS

Complete continence during daytime was achieved in 73% of patients with 6-month follow-up and in 86% at night. Significant increase in bladder capacity and bladder compliance was achieved in all patients. Residual urine was reduced significantly, resulting in a decrease of the incidence of urinary tract infections.

CONCLUSIONS

The treatment of neurogenic bladder dysfunction in spinal cord injury by anterior sacral root stimulation with the Finetech-Brindley stimulator in combination with sacral posterior root rhizotomy produces excellent results with limited morbidity.

Sacral rhizotomies and electrical bladder stimulation in spinal cord injury. 2. Cost-effectiveness and quality of life analysis. Dutch Study Group on Sacral Anterior Root Stimulation

OBJECTIVES

To present a cost-effectiveness analysis of sacral rhizotomies and electrical bladder stimulation compared with conventional care of neurogenic bladder dysfunction in patients with spinal cord injury.

METHODS

During a 3-year inclusion period, data on costs and quality of life before the intervention were collected to describe conventional care. Data on the pre-implantation period, the implantation and a follow-up period of 2 years were collected following a strict protocol simultaneous with medical and urodynamic data and were used to calculate the costs and effects on quality of life of the implantation of the stimulator.

RESULTS

Between June 1991 and June 1994, 52 patients with complete cervical or thoracic spinal cord lesions underwent sacral posterior rhizotomies and implantation of a Finetech-Brindley sacral anterior root stimulator. Although the initial costs of sacral anterior root stimulation are high, they are earned back in this series in about 8 years after the implantation. General indicators of the quality of life show no significant changes after the implantation. Factors related to psychological well-being and the patients' satisfaction with the emptying of the bladder increased significantly whereas the experienced problems of micturition and incontinence all decreased significantly.

CONCLUSION

Sacral rhizotomies and electrical bladder stimulation make a cost-effective method of treatment of lower urinary tract dysfunction in patients with spinal cord injury. Considerable savings on health care costs are possible in the long run with simultaneous positive effects on aspects of health status.

The genitofemoral nerve may link testicular inguinoscrotal descent with congenital inguinal hernia

The genitofemoral nerve (GFN) hypothesis for inguinoscrotal testicular descent proposes that calcitonin gene-related peptide (CGRP), released from the genitofemoral nerve, controls the migration of the gubernaculum from the inguinal region to the scrotum between 26 and 40 weeks of gestation. The processus vaginalis provides a channel through which the testis descends from the abdomen to the scrotum. Following descent of the testis the processus vaginalis undergoes luminal obliteration and disappearance between the internal inguinal ring and the upper pole of the testis. The mechanism underlying closure of the processus is unknown and failure for it to occur normally results in congenital inguinal hernia, scrotal hydrocele and possibly even an 'ascending' testis. Recent work in our laboratory suggests that CGRP, released from the genitofemoral nerve, may cause fusion and disappearance of the processus vaginalis. We propose that abnormalities in the GFN link a spectrum of disorders encompassing congenital undescended testis, inguinal hernia, scrotal hydrocele and ascending testis.

Nitric oxide control of lower genitourinary tract functions: a review

It is apparent that evolving concepts of the regulatory basis for functions in the pelvis must take into account the role exerted by nitric oxide. A recently characterized messenger molecule, nitric oxide has been associated with numerous physiologic processes. Intense investigations of this molecule have extended its importance to several genitourinary functions. Penile erection, micturition, peristalsis of the male excurrent duct system, contractile properties of the prostate, and lumbosacral spinal cord neurotransmission are all functions that may transpire under some degree of control by nitric oxide. Impotence, urinary obstruction, or ejaculatory problems, in turn, may represent alterations of nitric oxide production or action. The strategic manipulation of nitric oxide or its mechanism of action, possibly by pharmacologic means, may restore or produce desired functional effects. These possibilities, therefore, suggest that the advancing knowledge of nitric oxide in the genitourinary tract may be of enormous clinical value in the future.

Reduced variance of latencies in pudendal evoked potentials after normalization for body height

The value of the Somatosensory Evoked Potentials (SEP) in the assessment and detection of neurological disorders could be considerably enhanced if the normative standards of (SEP) characteristic parameters were normalized taking into account all other systematic sources of variance. The present study examines the influence of body height on the peak and interpeak latencies of the pudendal somatosensory evoked potentials. We examined the peak latency (L1) of the evoked potential recorded at the L1 vertebra and the onset latency (ONc) of the cortical evoked potentials, after stimulation of the pudendal nerve, as a function of body height in 40 normal male subjects (age 20-40 years). Significant positive correlation was found between both (ONc) latency and ONc-L1 interpeak latency and body height (H). Assuming that the latter is proportional to the length of the neural pathways, the experimental data were fitted using a theoretical model representing the conduction in the sensory neuraxis as a function of body height. Using the estimated fitting functions, we normalized our data with regard to a typical value of body height. The normalized values of the aforementioned latencies reveal a significantly reduced variance, as compared to the original ones, and consequently their diagnostic importance is significantly increased. Similar procedures applied to the L1 (spinal) latencies and the latencies of the bulbocavernosus reflex (BCR) reveal no correlation with body height and this is discussed on the basis of neuroanatomical considerations.

Surgical anatomy of the pudendal nerve and its clinical implications

A study of the surgical anatomy of the pudendal nerve (PN) was performed in 13 female and 7 male cadavers. The knowledge of the precise anatomy and anomalies of this important nerve would help in better localization of the nerve and its roots and branches for neurostimulation or for pudendal canal decompression in pudendal canal syndrome. Two routes were used in the dissection: gluteal and perineal. The PN was identified and its course was followed from its roots to its termination. The PN was composed of three roots derived from the 2nd, 3rd, and 4th anterior sacral rami (S 2,3,4). The roots received a contribution from S 1 in five cadavers and from S 5 in one. The three roots formed two cords. The first root continued as the upper cord while the second and third root fused together producing the lower cord. The PN was formed by union of the two cords a short distance proximal to the sacrospinous ligament, and then crossed the back of the ligament. In no specimen did the nerve cross the ischial spine. The inferior rectal nerve arose from the PN in the pudendal canal in 18 cadavers. In two cases it came out proximal to the canal; this would spare the two subjects the anorectal manifestations of the pudendal canal syndrome. As the PN crossed the back of the sacrospinous ligament, it gave origin to a branch that supplied the levator ani muscle. This branch was only found in male cadavers and we call it "accessory rectal nerve"; the levator ani muscle in such cadavers was doubly innervated on its perineal aspect.

Evaluation of the motor and sensory components of the pudendal nerve

Extensive neurophysiological investigations consisting of different techniques to evaluate the efferents and afferents of the pudendal nerve were carried out in 27 healthy subjects. These investigations included motor evoked potential recordings from the external anal sphincter in response to magnetic stimulation of the cortex and lumbosacral roots, measurement of sacral reflex latency to magnetic and electrical stimulation, and cortical sensory evoked potential recording after stimulation of the dorso-genital nerve and anal canal. Motor latencies after transcranial magnetic stimulation to the anal sphincter were 25.1 +/- 2.9 msec at rest and 20.9 +/- 2.0 msec with voluntary sphincter contraction (facilitation). Motor latency after lumbosacral root stimulation was 3.7 +/- 1.0 msec. Mean sacral reflex latency after magnetic stimulation was 43.8 +/- 11.2 msec and was significantly longer than after electrical stimulation (37.0 +/- 7.2 msec; P < 0.05). P1 latency of the sensory evoked potentials after dorso-genital nerve stimulation was 40 +/- 3 msec and was significantly shorter than after anal stimulation 46 +/- 3 msec (P < 0.01). Evoked potential recording allows us to study both upper and lower motor neuron components to the anal sphincter. The present study paves the way for the combined application of these tests in the evaluation of disorders of the pelvic floor.

Role of nitric oxide in sympathetic neurotransmission in opossum internal anal sphincter

BACKGROUND

The role of nitric oxide in the gut in response to sympathetic nerve stimulation has not been examined. The present study examined the influence of the NO synthase inhibitor L-NG-nitro-arginine (L-NNA) on responses to hypogastric nerve stimulation (HGNS) in the opossum internal anal sphincter (IAS).

METHODS

Resting pressures in the IAS (IASP) were monitored using low-compliance continuously perfused catheters.

RESULTS

The predominant response to HGNS was an elevation of the resting tone in the IAS. The other responses of infrequent nature were a decrease in the IASP and a biphasic response (an initial increase followed by a decrease in the IASP). beta-Adrenoceptor antagonist propranolol had no significant effect on the increase in the IASP by HGNS but almost abolished the decrease in the IASP caused by HGNS and unmasked the excitatory responses. The IAS responses to HGNS were frequency dependent and abolished by guanethidine (adrenergic blocker). L-NNA caused significant and stereoselective suppression of all IAS responses to HGNS. The suppressed HGNS responses were completely reversed by the NO precursor L-arginine stereoselectively. The NO synthase inhibitor and guanethidine had no effect on the increase in IASP by phenylephrine.

CONCLUSIONS

NO may play a significant role in the facilitatory modulation of sympathetic responses in the IAS.

Electromyography of the pelvic diaphragm and anal sphincter in dogs with perineal hernia

The innervation of the levator ani and coccygeal muscles and the external anal sphincter was studied by anatomic dissection in 6 clinically normal male dogs and by electrical stimulation in 5 clinically normal male dogs. Variations in innervation occasionally were found that were comparable to those reported in previous studies. Electromyographic recordings were made from the levator ani and coccygeal muscles and from the anal sphincter in 40 dogs during perineal hernia repair. Spontaneous potentials of 4 types were found in 35 dogs: fibrillation potentials, positive sharp waves, complex repetitive discharges, and fasciculations. Biopsy specimens of the cranial part of the levator ani muscle were taken in 12 dogs during perineal hernia repair. Histologic examination revealed atrophy in 7 specimens. Spontaneous potentials were recorded from all muscles with histologic evidence of atrophy. All examinations of the levator ani muscle concerned the cranial part of this muscle, because the caudal part was absent in all 40 dogs. From combined results of electromyography and histologic examination, it was concluded that atrophy of the muscles of the pelvic diaphragm, which develops in some dogs with perineal hernia, is likely to be of neurogenic origin. Nerve damage is localized in the sacral plexus proximal to the muscular branches of the pudendal nerve or in the muscular branches separately.

Prilocaine in lumbosacral plexus block--general efficacy and comparison of nerve stimulation amplitude

The significance of the threshold amperage of peripheral nerve stimulation (PNS) for the efficacy and latency of sciatic block is shown in a controlled randomized study of stimulation amplitude. In all cases the block was complete within a short time when the threshold amperage was 0.3 mA or less. Incomplete motor and sensory blocks occurred with higher stimulation amplitudes of 0.5 and 1.0 mA. In view of these results a prospective study of the clinical efficacy of 852 combined sciatic/3-in-1 blocks using prilocaine, and performed by means of peripheral nerve stimulation was carried out. No CNS or cardiovascular complications, no problems resulting from methaemoglobinaemia and, above all, no nervous lesions were observed. The limiting factor for surgery of the lower limb with this method of anaesthesia is the tolerance of the femoral tourniquet which depends mainly on the efficacy of the 3-in-1 block. Ninety-one per cent of the combined blockades were primarily successful when there was no tourniquet at all, and 87% when the tourniquet was placed on the lower leg. In the course of surgery with a femoral pneumatic tourniquet, only 55% of the blocks did not require supplement when 20 ml of 1% prilocaine was used for the 3-in-1 block, while 72% and 74% were efficacious with 30 ml and 35 ml, respectively. The efficacy of the sciatic block proved to be extremely high (> 95%), its success depending on the dosage of the local anaesthetic and correct execution of the peripheral nerve stimulation.

Response of bladder, urethral and intracavernous pressure to ventral lumbosacral root stimulation in Sprague-Dawley and Wistar rats

Six Sprague-Dawley and six Wistar rats were used for electrostimulation of the L5 to S2 ventral roots. Landmarks for identification of the roots were developed; bladder, urethral and intracavernous pressures were recorded; and tail and leg movements were checked. Urethral sphincter contraction was elicited by stimulation of the L5-L6 ventral roots, while bladder contraction and penile erection were mediated by the L6-S1 ventral roots. The best sphincteric response and intracavernous pressure rise were obtained by stimulation of the L6 ventral root, and the highest bladder pressures by stimulation of the S1 ventral root. Stimulation of the S1-S2 ventral roots provoked ipsilateral tail movement; of L6, tail movement, hindleg muscle twitch, and slight toe spread; and of L5, hindleg stretch and plantar flexion. No significant differences were found between the two strains of rats, although a higher bladder pressure was recorded during stimulation of the L6 ventral root in Sprague-Dawley rats, which might be explained by a small caudal shift of the sacral parasympathetic nucleus in the Wistar strain.

Lumbosacral nerve root stimulation comparing electrical with surface magnetic coil techniques

Stimulation of lumbosacral nerve roots using a monopolar needle electrode was compared with magnetic stimulation using a 7-cm diameter surface coil. Compound muscle action potentials were recorded from the tibialis anterior (TA) and flexor hallucis brevis (FHB) muscles. Although the mean latency of CMAPs did not differ using the two techniques, amplitudes were considerably larger using a needle. Mean amplitudes were 66% (TA) and 64% (FHB) of the direct M response obtained by distal, supramaximal stimulation compared with mean values using maximal magnetic coil stimulation of 36% (TA) and 25% (FHB). Minimum F-wave latencies from FHB were used to estimate the site of nerve root stimulation using both techniques. Although there was a large amount of variability in the data from individual subjects, the results suggested that, on the average, both forms of stimulation act proximal to the intervertebral foramen. We conclude that a needle electrode is a more suitable technique for stimulating lumbosacral nerve roots.

The sympathetic role as an antagonist of erection

The effects of the lumbar and pelvic sympathetic system on penile erection were studied in a canine model. Erection was induced by cavernous nerve stimulation and detumescence by sympathetic trunk stimulation. Erection induced by cavernous nerve stimulation normally subsides slowly. After discontinuation of electrical stimulation the intracavernous pressure drops within a mean of 291 s to 50% and after a mean of 372 s to 10% of the highest level. However, stimulation of the sympathetic trunk at the level of L4-S1 applied directly after discontinuation of cavernous nerve stimulation accelerated this drop of intracavernous pressure significantly: to 50% after a mean of 19 s and to 10% after a mean of 36 s. If stimulation of the sympathetic trunk was initiated 20 s before cavernous nerve stimulation, the pressure rise was aborted completely. Neurostimulation of the hypogastric nerves alone or in combination with cavernous nerve stimulation did not change the intracavernous pressure. These results were not altered after neurotomy of the pudendal or hypogastric nerves. The main pathway of the fibers from the sympathetic trunk to the penis seems to run via the pelvic plexus. The stimulation voltage and frequency to induce erection or detumescence were equivalent. Our results suggest that an elevated central sympathetic tone may be one of the causes of psychogenic impotence.

Role of neuropeptide Y in opossum internal anal sphincter

The present investigation was undertaken to examine the effects and role of neuropeptide Y (NPY) on the internal anal sphincter (IAS). The studies were performed in alpha-chloralose-anesthetized opossums. Resting pressure in the IAS (IASP) was recorded using low-compliant continuously perfused catheters. The effect of NPY administered close intra-arterially on the resting IASP was examined before and after different neurohumoral antagonists and the neurotoxin tetrodotoxin (TTX). To examine the influence of sympathetic nerves, the ventral roots of lumbar sympathetic nerves were isolated in some experiments and stimulated electrically. The influence of NPY on the IAS relaxation in response to rectoanal reflex mimicked by rectal balloon distension (RD) was also examined. NPY caused dose-dependent rise in the IASP, which was not modified by different neurohumoral antagonists and TTX. The rise in IASP by electrical stimulation of ventral lumbar nerve root (L3) was suppressed but not abolished by phentolamine. However, guanethidine (which depletes both norepinephrine and NPY) caused complete obliteration of this response. The other effect of NPY on the IAS was significant antagonism of IAS relaxation caused by RD. From these results, we conclude that NPY exerts two different actions on the IAS. First, it causes a rise in IASP by its action directly at the IAS smooth muscle. Sympathetic nerve stimulation may cause a rise in IASP by its action directly at the IAS smooth muscle partially through release of NPY. Second, it inhibits IAS relaxation produced by rectoanal reflex. These findings would suggest an important regulatory role of NPY in rectoanal physiology.

Technique of pudendal nerve localization for block or stimulation

A diagnostic technique is described for study of the pudendal nerve via a dorsal rather than perineal approach. The method offers unique advantages for the urodynamic study of sphincteric function. The patient is placed in the prone position with slight flexion of the hips. The position of the ischial spine is identified topographically using the ischial tuberosities, greater trochanter and lower edge of the ischial-tuberous ligament. Local anesthesia and electrical stimulation then are used to position a needle tip adjacent to the pudendal nerve. This approach allows for specific localization of the nerve for accurate temporary or permanent nerve block. It also permits continuous urodynamic monitoring of pelvic floor behavior with stimulation of the pudendal nerve to assess functional integrity of the nerve and the pelvic floor striated muscles.

Neuroanatomy and its clinical application

In years prior, articles concerned with neuroanatomy have stressed just that, the anatomy. It is for this reason that this article was written. The primary intent addresses the clinical aspects of neuroanatomy, and as such, has stressed so-called "anatomic function." An overview of neuroanatomy as well as neural function and deficit is provided. The article is intended for both the student and practitioner in the hopes of taking the labor out of its study and replacing it with a logical approach to the neuroanatomy and its clinical applications.

Urethral responses to sacral stimulation in chronic spinal dog

Urethral activity was investigated in the awake chronic spinal-injured canine using urodynamic recordings, video cystofluoroscopy, and urethral pressure recordings without anesthesia. Bladder contractions and voiding were induced by electrical stimulation with epidural electrodes inserted into the sacral canal. Urethral pressure remained elevated during stimulation and for 1-3 s afterward. Poststimulation voiding occurred with three different patterns: 1) pulsatile voiding in which squirting of urine was associated with contractions in the membranous urethra; 2) "on and off" voiding in which pulsatile flow was interrupted for brief periods of time; and 3) steady-stream voiding in which nonpulsatile flow was followed by pulsatile flow. Viewing these voiding patterns with fluoroscopy indicated that the proximal membranous urethra was important in all of the patterns. We conclude that in the chronic spinal-injured canine the skeletal muscle within the membranous urethra (rhabdosphincter) is involved in responses to sacral stimulation and various voiding patterns.

[Segmental (L4-S1) motor and sensory innervation of the lower extremity determined by electrical potentials]

Reliable knowledge of the segmental innervation of the muscles and skin of the lower extremity is required to evaluate the anatomical localization of the lumbosacral nerve root involvement. There exist a number of reports on the segmental innervation of the muscles and the area of skin supplied by the lumbosacral plexus. However, no universal acceptance on the lumbosacral nerve root innervation exists. In order to confirm the reliability of the information on myotomes and dermatomes that has been reported, muscle action potentials were recorded from 11 lower limb muscles of 10 subjects by electrical stimulation of the L4, L5 and S1 nerve roots. Sensory nerve potentials were also recorded from roots by stimulations of the sural nerve, superficial and deep peroneal nerve, and the 1st toe of 8 subjects. Under an image intensifier, the electrodes were inserted near the nerve root in the intervertebral foramen or the first sacral foramen. The medial and lateral head of gastrocnemius and the soleus were confirmed to be S1 innervation, but tibialis anterior had a dual innervation at L4 and L5. Extensor hallucis longus, extensor digitorum longus and brevis, and peroneus longus were supplied predominantly by L5. Abductor hallucis and the long head of biceps femoris were supplied by S1, and rectus femoris was supplied by the L4 root. The sural nerve and superficial peroneal nerve were supplied by S1 and L5 nerve root, respectively. The deep peroneal nerve was supplied by either L4 or L5. The 1st toe was supplied by L5.