Clinical and ultrasound characteristics of deep endometriosis affecting sacral plexus

OBJECTIVES

To describe sonomorphological changes and appearance of deep endometriosis (DE) affecting the nervous tissue of the sacral plexus (SP).

METHODS

This was a retrospective study of symptomatic female patients who underwent radical resection of histologically confirmed DE affecting the SP who had undergone preoperative transvaginal sonography (TVS). Between 2019 and 2023 lesions were described based on the terms and definitions of the International Deep Endometriosis Analysis (IDEA) group. DE affecting the SP was diagnosed on ultrasound by TVS, when sonographic criteria of DE were visualized in conjunction with fibers of the SP and the presence of related symptoms, so-called sacral radiculopathy. Clinical symptoms, ultrasound features and histological confirmation were analyzed for each patient included.

RESULTS

Twenty-seven patients with DE infiltrating the sacral plexus were identified in 2 contributing tertiary referral centers. Median age was 37 (range, 29-45) years and all of the patients were symptomatic and presented one or more of the following neurological symptoms: dysaesthesia in the ipsilateral lower extremity (n = 17), paraesthesia in the ipsilateral lower extremity (n = 10), chronic pelvic pain radiating in the ipsilateral lower extremity (n = 9), chronic pain radiating in the pudendal region (n = 8), weakness in the ipsilateral lower extremities (n = 3). All DE lesions affecting the SP were purely solid tumors in the posterior parametrium in direct contact with or infiltrating the S1 and/or S2 and/or S3 and/or S4 roots of the SP. The median of the largest diameter of the DE nodules was 35 mm and echogenicity of the DE nodules was in 86% (n=23) non-uniform. All but one of them contained hyperechoic areas. The shape of the lesions was in 89% (n=24)irregular. Only one lesion exhibited lobulated form, all other irregular lesion showed spiculated appearance. 74% (n=20) of the nodules gave an acoustic shadow, all of them internal. With color or power Doppler examination 78% (n=21) of the nodules showed no signal (Color Score 1). The remaining 22% (n=6) of the lesions manifested only a minimal color content (Color Score 2). According to pattern recognition, most DE nodules were a purely solid non-uniform hypoechoic nodule with hyperechoic areas, internal shadows and irregular spiculated contours and poorly vascularized at color/power Doppler examination.

CONCLUSION

The ultrasound finding of a parametrial unilateral solid non-uniform hypoechoic nodule with hyperechoic areas and possible internal shadowing as well as irregular spiculated contours demonstrating poor vascularization on Doppler examination in proximity or involving the structures of the SP reflects DE affecting these structures. This article is protected by copyright. All rights reserved.

Circum-Psoas Block versus Supra-Inguinal Fascia Iliaca Block for Postoperative Analgesia in Patients Undergoing Total Hip Arthroplasty: A Randomized Clinical Trial

Purpose

Total hip arthroplasty (THA) is often associated with moderate to severe pain. The present study compared the efficacy of circum-psoas block (CPB) with supra-inguinal fascia iliaca block (SIFIB) for postoperative analgesia in patients undergoing THA.

Patients and Methods

In this randomized trial, sixty-four patients undergoing THA were allocated randomly to the CPB group or SIFIB group with 40 mL of 0.3% ropivacaine. The primary outcome was dynamic pain score at 6 h postoperatively. Secondary outcomes included dynamic pain scores at 12, 24 and 48 h; static pain scores; sensory and motor block; opioid consumption; time to first opioid request; length of hospital stay; patient satisfaction; and adverse events.

Results

CPB patients showed significantly lower dynamic pain scores at 6 (3.11 ± 0.66 vs 4.47 ± 0.74, respectively; P = 0.000), 12 (2.52 ± 0.73 vs 3.53 ± 0.85, respectively; P = 0.000) and 24 h (2.30 ± 0.57 vs 2.87 ± 0.71, respectively; P = 0.001) after surgery, as well as lower static pain scores at 6 and 12h (P = 0.001 and P = 0.033 respectively) than SIFIB patients. Lower opioid consumption was observed in the CPB group at 24 and 48 h (P = 0.000, both) than in the SIFIB group. Patients in the CPB group reported improved quadriceps strength at 6 and 12 h (P = 0.000, both), as well as better muscle strength of hip flexion at 6, 12 and 24 h (P = 0.000, P = 0.000 and P = 0.025 respectively). Compared with SIFIB, CPB was associated with increased sensory block coverage at 6, 12 and 24 h (P = 0.000, P = 0.000, and P =0.022, respectively).

Conclusion

CPB has a greater potential to alleviate postoperative pain and improve recovery in THA patients than SIFIB.

Visualization of sacral nerve roots and sacral plexus on gynecological transvaginal ultrasound: feasibility study

OBJECTIVE

To investigate the feasibility of identifying and measuring the normal sacral plexus (SP) on gynecological transvaginal ultrasound (TVS) examination.

METHODS

This was a prospective observational study conducted at a single tertiary gynecological referral center, including consecutive women undergoing TVS for various indications between November 2021 and January 2022. A standardized assessment of the pelvic organs was performed and the presence of any congenital or acquired uterine pathology or ovarian abnormality was recorded. Visualization of the right and left SP was attempted in all cases. The success rate and the time needed to identify the SP were recorded and measurements of the SP were made.

RESULTS

A total of 326 patients were included in the study. In all women, the SP was identified successfully on at least one side. SP were visualized bilaterally in 317 (97.2% (95% CI, 94.4-98.5%)) women. Only the right SP was seen in 3/326 (0.9% (95% CI, 0.2-2.7%)) and only the left in 6/326 (1.8% (95% CI, 0.6-4.0%)) (P = 0.5048). There was no significant difference in the median time required to visualize the right vs left SP (9.0 (interquartile range (IQR), 8.0-10.0) s  vs 9.0 (IQR, 8.0-10.0) s; P = 0.0770). The median transverse diameter of the right SP was 15.0 (IQR, 14.2-15.6) mm and that of the left SP was 14.9 (IQR, 14.4-15.6) mm.

CONCLUSIONS

We describe a novel method which allows for the consistent and rapid identification of the SP on TVS. Integrating assessment of the SP into routine pelvic TVS may be helpful particularly for women suffering from deep endometriosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Parasacral ischial plane block for lower limb wound debridement surgeries - A case series

Parasacral ischial plane block is a novel fascial plane approach to sacral plexus. Parasacral ischial plane block is technically less challenging and obviates the need for direct visualisation of sacral plexus. It can reliably be performed in limb-amputated patients where neuromuscular stimulation is less useful. Ten patients of the American Society of Anesthesiologists physical status II-IV, aged between 18 and 70 years, posted for elective lower limb debridement surgeries were enroled in this prospective case series. The time taken to perform the block was ≤4 minutes in all cases. Time taken for full sensory loss was 9 minutes to 15 minutes. None of the patients developed a complete motor blockade till 30 minutes after our observation. None of the patients required intraoperative supplemental analgesia. This block is technically easy, less time-consuming, and provided adequate sensory analgesia in below-knee surgeries.

Simultaneous Posterior Femoral Cutaneous Nerve and Sciatic Nerve Variations: A Case Report

During the routine dissection of a formalin fixed Caucasian cadaver, a previously unreported variation of the sacral plexus was found in the right gluteal region. The posterior femoral cutaneous nerve was found to pierce the piriformis muscle as opposed to running along its more common course below the muscle. At the same level of the posterior femoral cutaneous nerve, the common fibular nerve also pierced the piriformis muscle, while the tibial nerve passed inferior to the piriformis muscle. No other anatomical variations were found.

Excision of deep endometriosis nodules of the parametrium and sacral roots in 10 steps

OBJECTIVE

To present 10 consecutive, standardized, and reproducible surgical steps allowing complete excision of deep endometriosis nodules infiltrating the parametrium and sacral roots.

DESIGN

Surgical video presenting the 10 surgical steps. Local institutional review board approval was not required for this video article, because the video describes a technique and the patient cannot be identified whatsoever.

SETTING

Endometriosis Center.

PATIENTS

Patients undergoing excision of deep endometriosis nodules of the parametrium and sacral roots.

INTERVENTION

The excision of deep endometriosis infiltrating the parametrium down to the sacral roots may be performed following 10 steps: complete ureterolysis and removal of ureteral stenosis; opening of the pararectal space in contact with the rectum in a sagittal plane; dissection caudally toward the rectovaginal space, section of the rectovaginal nodule in two separate blocks infiltrating the rectum and vagina, respectively, all the way down to the levator ani muscles; dissection of the presacral space and identification of the superior hypogastric plexus and hypogastric nerve; transverse incision of the peritoneum at the level of the promotorium, extended laterally above the origin of the hypogastric vessels; anterograde dissection of the hypogastric artery and identification of the hypogastric vein; anterograde dissection of the hypogastric vein and opening of Okabayashi space, followed by identification and, when required, ligation of hypogastric vein tributaries; dissection is extended behind the venous network with identification of the pyriform muscles and sacral roots S2, S3, and S4; anterograde dissection of the nerve network and inferior hypogastric plexus, up to the posterior limits of the deep endometriosis nodule; and excision of the deep endometriosis nodule from the posterior limit to the inferior limit in contact with the sacral roots, which should be released or shaved, then to the lateral limit in contact with the pyriform muscle and lateral pelvic wall. Additional steps may be required to remove adjacent infiltration of the vagina, rectum, bladder, or ureters. The movie does not reflect a similar approach in cases of isolated nodules of the sciatic nerves involving a specific lateral dissection plane between the external iliac vessels and the iliopsoas muscle.

MAIN OUTCOME MEASURES

Description of 10 successive surgical steps.

RESULTS

The 10-step procedure already has been employed in 70 women with deep endometriosis of the parametria involving sacral roots, in whom sensory or motor complaints were not completely relieved by continuous amenorrhea provided by contraceptive pill intake or gonadotropin-releasing hormone analogs. Baseline complaints included somatic pain (85.7%), severe bladder dysfunction (10%), or hydronephrosis (24.3%). Main localizations concerned sacral roots (95.7%), sciatic nerves (7.1%), mid/low rectum (87.1%), and bladder (21.4%). Operative time was 224 ± 94 minutes. Among postoperative complications, we recorded rectovaginal fistulae (14.3%), urinary tract fistulae (4.3%), and bladder dysfunction at 3 weeks (22.9%) and 12 months (5.7%) after the surgery.

CONCLUSIONS

Laparoscopic excision of deep endometriosis nodules of the parametria involving the sacral roots is a challenging procedure, requiring good anatomic and surgical skills. Teaching such a complex procedure is a delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the hypogastric venous network, preserve as much as possible autonomic nerves and organ function, and successfully excise deep endometriosis nodules. However, transection of the internal iliac artery and vein should not be systematic, as it may adversely affect the vascular supply of the pelvis. Transection of small pelvic splanchnic nerves should be performed only if they actually are included in fibrous nodules, as it may be followed by sexual, bladder, and rectal dysfunction or perineal sensory effects. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and their use should be individualized.

The majority of piriformis muscles are innervated by the superior gluteal nerve

The piriformis muscle is clinically implicated in pain disorders, posterior approaches for total hip arthroplasty, and iatrogenic injury to the muscle and the surrounding nerves. The piriformis muscle has been said to receive innervation from L5 to S3 ventral rami with most sources using S1 and S2 ventral rami as the most common innervation this muscle. However, descriptions of the nerve in the literature are vague. Therefore, the aim of this study was to clarify the anatomy of the nerve supply to the piriformis muscle. Twenty sides from ten fresh-frozen cadavers were studied. Specifically, via anterior dissection of the sacral plexus, branches to the piriformis were identified. Once identified, the nerves to the piriformis muscle were traced proximally to clarify their origin. Nerves supplying the piriformis muscle existed on all sides. On 80% of sides, the piriformis was innervated by two to three nerves. The origin of these nerves was from the superior gluteal nerve on 14 sides (70%), inferior gluteal nerve on one side (5%), L5 ventral ramus on one side (5%), S1 ventral ramus on 17 sides (85%), and S2 ventral ramus on 14 sides (70%), respectively. The most common nerve branches to the piriformis are from the superior gluteal nerve, and the ventral rami of S1 and S2. Based on our study, a single "nerve to piriformis" does not exist in the majority of specimens thus this term should be abandoned. Clin. Anat. 32:282-286, 2019. © 2018 Wiley Periodicals, Inc.

An update around the evidence base for the lower extremity ultrasound regional block technique

Ultrasound guidance currently represents the gold standard for regional anesthesia. In particular for lower extremity blocks, despite the heterogeneity and the lack of large randomized controlled trials, current literature shows a modest improvement in block onset and quality compared with other localization techniques. This review aims to present the most recent findings on the application of ultrasound guidance for each single lower extremity approach.

Complicated abdominal pregnancy with placenta feeding off sacral plexus and subsequent multiple ectopic pregnancies during a 4-year follow-up: a case report

BACKGROUND

Abdominal pregnancy (pregnancy in the peritoneal cavity) is a very rare and serious type of extrauterine gestation that accounts for approximately 1.4% of all ectopic pregnancies. It also represents one of the few times an ectopic pregnancy can be carried to term. Early strategic diagnosis and management decisions can make a critical difference with regards to severity of morbidity and mortality risk. After an extensive search of the English language medical literature, we are unaware of any case of abdominal pregnancy in which the placenta was receiving its vascular supply from the sacral plexus.

CASE PRESENTATION

A 26-year-old African-American woman, primigravida, at 16 weeks 4 days' gestation, presented to our Emergency Department with abdominal pain. She did not complain of any vaginal bleeding. A physical examination revealed mild abdominal tenderness and no blood in the vaginal vault. Laboratory findings corresponded to an increased level of beta human chorionic gonadotropin; magnetic resonance imaging confirmed an abdominal pregnancy. She underwent feticide, administration of methotrexate and a laparotomy was done which was immediately deferred due to perceived increased bleeding risk. She was found to have an intra-abdominal ectopic pregnancy with the placenta attached to her omentum, cul-de-sac and rectosigmoid, with unusual and extensive vascularity from the sacral plexus. A repeat laparotomy was performed 11 weeks later, aimed at removal of the gestational sac and placenta that were left in situ on the first laparotomy. This time, we achieved successful removal of the peritoneal gestation, lysis of adhesions, ligation of vascular supply and cautery of the diminished vasculature. Subsequently, she had two ectopic pregnancies, which were managed with both medical and surgical interventions.

CONCLUSIONS

Ectopic pregnancies should be identified early and evaluated for the etiology of the presentation. Rarely, an ectopic pregnancy implants at an extratubal location. Today, early intervention saves lives and reduces morbidity, but ectopic pregnancy still accounts for 4 to 10% of pregnancy-related deaths and leads to a high incidence of ectopic site gestations in future pregnancies. Medical management has emerged as a safe alternative to surgery and holds promise for preservation of future fertility; however, surgery remains an acceptable modality. We found that careful and strategic choice of management pathway can make all the difference to a favorable outcome. As emergency physicians, we need to be aware of the possibility of abdominal ectopic pregnancy in such presentations and its severe consequences if it remains undiagnosed.

Topography and landmarks for the nerve supply to the levator ani and its relevance to pelvic floor pathologies

The aim of this study was to explore the anatomical variations of the nerve to the levator ani (LA) and to relate these findings to LA dysfunction. One hundred fixed human female cadavers were dissected using transabdominal, gluteal, and perineal approaches, resulting in two hundred dissections of the sacral plexus. The pudendal nerve and the sacral nerve roots were traced from their origin at the sacral foramina to their termination. All nerves contributing to the innervation of the LA were considered to be the nerve to the LA. Based on the spinal nerve components, the nerve to the LA was classified into the following categories: 50% (n = 100) originated from S4 and S5 (type I); 19% (n = 38) originated from S5 (type II); 16% (n = 32) originated from S4 (type III); 11% (n = 22) originated from S3 and S4 (type IV); 4% (n = 8) originated from S3, S4, and S5 (type V). Two patterns of nerve termination were observed. In 42% of specimens, the nerve to the LA penetrated the coccygeus muscle and assumed an external position along the inferior surface of the LA muscle. In the remaining 58% of specimens, the nerve crossed the superior surface of the coccygeus muscle and continued along the superior surface of the iliococcygeus muscle. Damage to the nerve to LA has been associated with various pathologies. In order to minimize injuries during surgical procedures, a thorough understanding of the course and variations of the nerve to the LA is extremely important.