Minimally Invasive Approaches for Lumbosacral Plexus Schwannomas

BACKGROUND AND OBJECTIVES

Lumbosacral plexus schwannomas (LSPSs) are benign, slow-growing tumors that arise from the myelin sheath of the lumbar or sacral plexus nerves. Surgery is the treatment of choice for symptomatic LSPSs. Conventional retroperitoneal or transabdominal approaches provide wide exposure of the lesion but are often associated with complications in the abdominal wall, lumbar or sacral plexus, ureter, and intraperitoneal organs. Advances in technology and minimally invasive (MIS) techniques have provided alternative approaches with reliable efficacy compared with traditional open surgery. We describe 3 MIS approaches using tubular retractor systems according to the lesion level.

METHODS

This was a multicenter, retrospective observational cohort study to evaluate the use of MIS tubular approaches for surgical resection of LSPSs. We included 23 lumbar and upper sacral plexus schwannomas. Clinical presentation, spinal level, surgical duration, degree of resection, days of hospitalization, pathological anatomy of the tumor, approach-related surgical difficulties, and outcomes were collected.

RESULTS

The posterior oblique approach was used in 43.5% of the cases, the transpsoas approach in 39.1%, and the transiliac in 17.4%. The mean operative time was 3.3 hours, and the mean hospitalization was 2.5 days. All tumors were WHO grade 1 schwannoma. Postoperative MRI confirms gross total resection in 91.3% of the patients. No patient requires instrumentation. The pros and cons of each approach were summarized.

CONCLUSION

The MIS approaches adapted to the lumbar level may improve surgeons' comfort allowing a safe resection of retroperitoneal LSPS.

Surgical and oncologic outcomes in dogs with malignant peripheral nerve sheath tumours arising from the brachial or lumbosacral plexus

Malignant peripheral nerve sheath tumours (MPNST) of a plexus nerve or nerve root cause significant morbidity and present a treatment challenge. The surgical approach can be complex and information is lacking on outcomes. The objective of this study was to describe surgical complication rates and oncologic outcomes for canine MPNST of the brachial or lumbosacral plexus. Dogs treated for a naïve MPNST with amputation/hemipelvectomy with or without a laminectomy were retrospectively analysed. Oncologic outcomes were disease free interval (DFI), overall survival (OS), and 1- and 2-year survival rates. Thirty dogs were included. The surgery performed was amputation alone in 17 cases (57%), and amputation/hemipelvectomy with laminectomy in 13 cases (43%). Four dogs (13%) had an intraoperative complication, while 11 dogs (37%) had postoperative complications. Histologic margins were reported as R0 in 12 dogs (40%), R1 in 12 dogs (40%), and R2 in five dogs (17%). No association was found between histologic grade and margin nor extent of surgical approach and margin. Thirteen dogs (46%) had recurrence. The median DFI was 511 days (95% CI: 140-882 days). The median disease specific OST was 570 days (95% CI: 467-673 days) with 1- and 2-year survival rates of 82% and 22% respectively. No variables were significantly associated with recurrence, DFI, or disease specific OST. These data show surgical treatment of plexus MPNST was associated with a high intra- and postoperative complication rate but relatively good disease outcomes. This information can guide clinicians in surgical risk management and owner communication regarding realistic outcomes and complications.

Exposure of the Lumbosacral Plexus by Using the Pararectus Approach: A Technical Note

BACKGROUND

Surgical exploration of the lumbosacral plexus is challenging. Previously described approaches reach from invasive open techniques with osteotomy of the ilium to laparoscopic techniques.

OBJECTIVE

To describe a novel surgical technique to explore lumbosacral plexopathies such as benign nerve tumors or iatrogenic lesions of the lumbosacral plexus in 4 case examples.

METHODS

We retrospectively evaluated 4 patients suffering from pathologies or injuries of the lumbosacral plexus between 2017 and 2019. The mean follow-up period after surgery was 23.5 (range 11-52) months. All patients underwent neurolysis of the lumbosacral plexus using the single incision, intrapelvic, extraperitoneal pararectus approach.

RESULTS

In all patients, the pathology of the lumbosacral plexus was successfully visualized, proving feasibility of the extraperitoneal pararectus approach for this indication. There were no major complications, and all patients recovered well.

CONCLUSION

The pararectus approach allows excellent visualization of the lumbar plexus and intrapelvic lesions of the femoral and sciatic nerves.

Effects of thigh extension on the position of the femoral nerve: application to prone lateral transpsoas approaches to the lumbar spine

Some authors have suggested that thigh extension during the prone lateral transpsoas approach to the lumbar spine provides the theoretical advantage of providing posterior shift of the psoas muscle and plexus and is responsible for its lower rates of nerve injury. We aimed to elucidate the effects of surgical positioning on the femoral nerve within the psoas muscle via a cadaveric study. In the supine position, 10 fresh frozen adult cadavers had a metal wire secured to the pelvic segment of the femoral nerve and then extended proximally along with its L2 contribution. Fluoroscopy was then used to identify the wires on the femoral nerves in a neutral position and with the thigh extended and flexed by 25 and 45°. Additionally, a lateral incision was made in the anterolateral abdominal wall to mimic a lateral transpsoas approach to the lumbar spine, and measurements were made of the amount of movement in the vertical plane of the femoral nerve from neutral to then 25 and 45° of thigh flexion and extension. On fluoroscopy, the femoral nerves moved posteriorly at a mean of 10.1 mm with thigh extension. Femoral nerve movement could not be detected at any degree of this range of flexion of the thigh. Extension of the thigh to about 30° can move the femoral nerve farther away from the dissection plane by approximately one centimeter. This hip extension not only places the femoral nerve in a more advantageous position for lateral lumbar interbody fusion procedures but also helps to promote accentuation of lumbar lordosis.

Surgical Management of Symptomatic Lumbar, Sacral, and Lumbosacral Plexus Tumors: a Peripheral Nerve Unit Experience

OBJECTIVE

Data concerning the surgical treatment of lumbosacral plexus tumors (LSPTs) is scarce. This study aims to present our experience with a series of 19 patients surgically treated for symptomatic LSPTs at our institution.

METHODS

This is a retrospective study of 19 patients surgically treated for symptomatic LSPTs from 2011 to 2019. Clinical data were retrieved from medical records and consisted of age, gender, clinical presentation, location of the lesion, surgical approach, final histopathologic diagnosis, follow-up time, outcomes, and complications.

RESULTS

Nineteen surgical procedures were conducted. Thirteen patients were female and six, male. The median age of patients was 45 years (range 20 to 63 years). No patients harbored genetic syndromes. Surgical treatment appears to be correlated to the reduction of pain in patients with peripheral nerve sheath tumors (PNSTs), as assessed by visual analog scale (VAS). Sixteen patients did not present with new-onset deficits during follow-up (84.2%), two of whom recovered from their preoperative deficit. Four patients presented with postoperative weakness. The histopathological diagnoses were 11 schwannomas, four neurofibromas, three metastases, and one lymphoma.

CONCLUSIONS

LSPTs are rare. When surgical treatment is indicated, it usually requires multidisciplinary management. Surgery appears to be effective concerning the reduction of pain in PNSTs and may also recover neurological deficits. Iatrogenic neurological deficits are an evident risk, such that intraoperative multimodal monitoring should always be performed if available. In lesions involving the sacral plexus, we found it to be indispensable.

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.

A study to improve identification of the retroperitoneal course of iliohypogastric, ilioinguinal, femorocutaneous and genitofemoral nerves during laparoscopic triple neurectomy

BACKGROUND

Laparoscopic triple neurectomy is an available treatment option for chronic groin pain, but a poor working knowledge of the retroperitoneal neuroanatomy makes it an unsafe technique.

OBJECT

Describe the retroperitoneal course of iliohypogastric, ilioinguinal, lateral femoral cutaneous and genitofemoral nerves, to guide the surgeon who operates in this region.

METHODS

Fifty adult cadavers were dissected resulting in 100 anatomic specimens. Additionally, 30 patients were operated for refractory chronic inguinal pain, using laparoscopic triple neurectomy. All operations and dissections were photographed. Measurements were made between the nerves of the lumbar plexus and various landmarks: interneural distances in a vertical midline plane, posterior or anterior iliac spine and branch presentation model.

RESULTS

The ilioinguinal and iliohypogastric nerves were independent in 78% (Type II) and separated by an average of 2.5 ± 0.8 cm. In surgery study, only 38% were recognized as Type II and at a significantly greater distance (3.5 ± 1.2 cm, p < 0.001). The distance between ilioinguinal and lateral femoral cutaneous nerves was also greater during surgery, with statistical significance (5.1 ± 1.5 versus 4.2 ± 1.5, p < 0.005). The distance of the nerves to their bone references were not statistically different. The genitofemoral nerve emerged from the psoas major muscle in 20% as two separate branches (Type II), regardless of the study. The lateral femoral cutaneous nerve had a mean distance of 0.98 ± 1.6 cm medial to the anterior superior iliac spine.

CONCLUSION

The identification of the IH, II, FC and GF nerves is essential to reduce the rate of failures in the treatment of CGP. The frequent anatomical variations of the lumbar plexus nerves make knowledge of their courses in the retroperitoneal space essential to ensure safe surgery. The location of the nerves in the LTN is distorted by up to 1 cm. regarding references in the cadavers.

Novel Implementation of Extreme Lateral Interbody Fusion to Avoid Intraoperative Lumbar Plexus Injury: Technical Note and Preliminary Results

BACKGROUND

This study modified the traditional extreme lateral lumbar interbody fusion (XLIF) surgery and was intended to reduce the approach related to lumbar plexus injury.

METHODS

The patients receiving a new modified XLIF for treatment of lumbar degenerative diseases since September 2017 in our hospital were retrospectively collected. Postoperative additional symptoms of leg numbness, pain, or weakness were recorded as lumbar plexus nerve injury. Intraoperative electromyographic monitoring was recorded during surgery to evaluate the safety of the modified entry point. The visual analog scale and Oswestry Disability Index were adopted to evaluate the postoperative clinical efficacy. Modified MacNab criteria were introduced to evaluate the patients' satisfaction 12 months after surgery. The preoperative and postoperative intervertebral height, foraminal height, and lumbar lordotic angle were measured. Repeated measurement variance analysis was used for comparison of clinical and imaging indexes in various periods. P < 0.05 indicated statistical difference.

RESULTS

Fifty-nine patients were finally included in the retrospective study. The intraoperative average blood loss and operation time were 70 mL (40-130 mL) and 77.90 ± 13.65 minutes. The average follow-up time was 18 months. Postoperative visual analog scale and Oswestry Disability Index were significantly decreased compared with those before the operation. The intervertebral height and foraminal height were dramatically higher than those before surgery. No lumbar plexus injury occurred.

CONCLUSIONS

The initial result was optimistic in reducing lumbar plexus injury and obtaining good clinical efficacy. We need to further expand the sample size and carry out a comparative study to observe the advantages and disadvantages of modified XLIF.

[Deliberations on lumbar sympathectomy: years and practice on the occasion of the 90th anniversary of using the method in Russia]

The article deals with the literature data on history of and modern attitude to lumbar sympathectomy in treatment for occlusive lesions of lower-limb peripheral arteries. This is followed by analysing the experience of 1,764 operations both independent and those combined with vascular reconstructions over more than a 45-year period. A conclusion is drawn that lumbar sympathectomy remains an operation associated with minimal traumaticity and a low complication rate, thus for long years improving the quality of life and destiny of patients.

Lumbar sympathectomy techniques for critical lower limb ischaemia due to non-reconstructable peripheral arterial disease

BACKGROUND

Critical lower limb ischaemia (CLI) is a manifestation of peripheral arterial disease (PAD) that is seen in patients with typical chronic ischaemic rest pain or patients with ischaemic skin lesions - ulcers or gangrene - for longer than 2 weeks. Critical lower limb ischaemia is the most severe form of PAD, and interventions to improve arterial perfusion become necessary. Although surgical bypass has been the gold standard for revascularisation, the extent or the site of disease may be such that the artery cannot be reconstructed or bypassed. These patients require other modalities of treatment, for example, vasodilatation by drugs or lumbar sympathectomy to relieve pain at rest and to avoid amputations. A systematic review of randomised controlled trials is required to evaluate the effects of lumbar sympathectomy in treating patients with CLI due to non-reconstructable PAD.

OBJECTIVES

The objective of this review is to assess the effects of lumbar sympathectomy by open, laparoscopic and percutaneous methods compared with no treatment or compared with any other method of lumbar sympathectomy in patients with CLI due to non-reconstructable PAD.

SEARCH METHODS

The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (January 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 12). In addition, the CIS searched clinical trials databases for details of ongoing and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any of the treatment modalities of lumbar sympathectomy, such as open, laparoscopic and chemical percutaneous methods, with no treatment or with any other method of lumbar sympathectomy for CLI due to non-reconstructable PAD were eligible. To decrease the bias of including participants that may be incorrectly diagnosed with CLI, review authors defined CLI as persistently recurring ischaemic rest pain requiring regular analgesia for more than two weeks, or ulceration or gangrene of the foot or toes, attributable to objectively proven arterial occlusive disease by measurement of ankle pressure of < 50 mmHg or toe pressure < 30 mmHg. We defined non-reconstructable PAD as a resting ankle brachial index (ABI) < 0.9 when no reasonable open surgical or endovascular revascularisation treatment option is available, as determined by individual trial vascular specialists.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies identified for potential inclusion in the review. We planned to conduct data collection and analysis in accordance with the Cochrane Handbook for Systematic Review of Interventions.

MAIN RESULTS

We identified no studies that met the predefined inclusion criteria. To decrease the bias of including participants who may be incorrectly diagnosed with CLI, we based our inclusion criteria on objective tests, as described above. The randomised trials identified by the literature search were performed before such objective criteria for selection were applied and therefore were not eligible for inclusion in the review.

AUTHORS' CONCLUSIONS

We identified no RCTs assessing effects of lumbar sympathectomy by open, laparoscopic and percutaneous methods compared with no treatment or compared with any other method of lumbar sympathectomy in patients with CLI due to non-reconstructable PAD. High-quality studies are needed.

Management of Plantar Hyperhidrosis with Endoscopic Lumbar Sympathectomy

Primary plantar hyperhidrosis is defined as excessive secretion of the sweat glands of the feet and may lead to significant limitations in private and professional lifestyle and reduction of health-related quality of life. Conservative therapy measures usually fail to provide sufficient relieve of symptoms and do not allow long-lasting elimination of hyperhidrosis. Endoscopic lumbar sympathectomy appears to be a safe and effective procedure for eliminating excessive sweating of the feet and improves quality of life of patients with severe plantar hyperhidrosis.

Novel Single Puncture Approach for Simplicity 3 Sacral Plexus Radiofrequency Ablation: Technical Note

Radiofrequency (RF) ablation of the lateral sacral plexus has been used for the treatment of sacroiliac joint pain including as an adjunct to other palliative therapies for the treatment of painful osseous metastasis. The treatment goal is targeted ablation of the dorsal lateral branches of S1-S4. Though several techniques have been described, the Simplicity III (Neurotherm, Middleton, MA) system allows for ablation to be achieved with a single RF probe by utilizing a multi-electrode curved RF probe to create a continuous ablation line across all sacral nerves. In the standard approach, there is sequential introduction of a spinal needle along the desired ablation tract for local anesthesia followed by separate placement of the ablation probe. Though fluoroscopic guidance is utilized, multiple needle passes increase the risk of complication such as bowel perforation or probe insertion through a neural foramen. It may also extend procedure time and increase radiation dose. We illustrate a technique for Simplicity III RF ablation of the dorsal sacral plexus using a modified Seldinger approach for treatment of a patient with sacroiliac joint pain due to osseous renal cell carcinoma metastasis. The desired ablation tract is initially anesthetized via a hollow micropuncture needle. The needle is then exchanged for a peelaway sheath. The RF probe is inserted through the peelaway sheath thus ensuring the probe is placed precisely along the previously anesthetized tract allowing the procedure to be completed using a single percutaneous puncture. We believe that this approach decreases the risks of bowel perforation, patient discomfort as a result of multiple percutaneous punctures, and procedure time.

KEY WORDS

Simplicity 3, sacral plexus ablation, image-guided approach, modified Seldinger, chronic sacral pain, thin wall introducer needle.

[Severe Raynaud's syndrome treated by lumbar sympathectomy]

Avoiding exposure of extremities to cold combined with pharmacologic treatment usually suffice in the attempt to suppress the related symptoms of Raynaud's syndrome. This case report describes a severe case of Raynaud's syndrome affecting the lower extremities of a 16-year-old female. She was referred to a centre of vascular surgery with severe vasospasms of the feet. After failed attempts of pharmacologic treatment, a laparoscopic lumbar sympathectomy was performed with no complications and a slight reduction of symptoms three years post-surgically.

[Lumbar sympathectomy literature review over the past 15 years]

INTRODUCTION

Lumbar sympathectomy (LS) irreversibly damages a part of the sympathetic trunk and adjacent ganglia between L1 and L5, typically between L2 and L4. The first LS was performed in 1923. Initially, it used to be performed very often; however, with the progress of vascular and endovascular surgery its importance gradually continues to decline. The aim of the paper is to present literature review focusing on LS over the past 15 years.

METHOD

Literature review of 113 academic articles found in academic journal databases.

PATHOPHYSIOLOGY

Irreversible interruption of the efferent innervation leads to relative vasodilation of small vessels in lower extremities (α1-receptors blockade), and it reduces the volume of sweat due to inactivation of eccrine glands and nociception from lower limbs.

INDICATION

Raynaud´s phenomenon, thromboangitis obliterans, non-revascularizable peripheral arterial disease (PAD) (Fontain grade III-IV), hyperhidrosis, persistent pain in lower extremities, chronic pain of amputation stump, frostbites, chilblains.Effect: The three largest studies showed a positive effect in 63.6-93.4% cases of PAD and in 97%100% cases of hyperhidrosis. The positive effect was defined as warmer lower extremities, increased blood flow, acceleration of chronic defects healing, sweating disappearance and pain reduction.

CONCLUSION

Lumbar sympathectomy still remains a useful method in the treatment of above mentioned diseases if properly indicated.

KEY WORDS

lumbar sympathectomy - Raynaud´s phenomenon - thromboangitis obliterans -peripheral arterial disease - hyperhidrosis.

Sacral Nerve Stimulation in the Treatment of Bowel Disorders

Defecation problems occur in patients of all ages, but are more prevalent in the elderly, postpartum women, and patients with chronic and debilitating medical conditions. Most of the time, these problems respond to medical therapy and nonsurgical options, but it is not uncommon for patients to require surgical intervention. Sacral nerve stimulation (SNS) presents an alternative for patients with bowel dysfunction combining proven therapeutic benefits and limited surgical risks. Here we describe the common indications for SNS, patient selection, technical details of the procedure, published outcomes, and complications that can arise. Based on our review, SNS is an effective treatment option for fecal incontinence and may reduce the patients' clinical symptoms and help restore their quality of life. Future research studies may expand the role of this modality for other bowel disorders.

Sacral Neuromodulation for Genitourinary Problems

Sacral neuromodulation (SNM) is a minimally invasive therapeutic option for many voiding dysfunction conditions. It is approved by the US FDA for refractory overactive bladder with and without incontinence and nonobstructive retention. Since SNM has shown a favorable response for these approved indications, other therapeutic applications have been proposed for various conditions such as painful bladder syndrome, chronic pelvic pain and neurological voiding dysfunction in both adult and pediatric age groups. SNM therapy with the most commonly used dedicated SNM device (InterStim) involves insertion of electrode(s) in the third and/or fourth sacral foramen next to the nerve root. The electrode is then connected to a battery-operated pulse generator. All patients need to have a test trial period before definitive device insertion. Here we discuss SNM therapy in functional urinary disorders and the technique of device insertion with the potential pitfalls.

Resection of Ileoinguinal and Ileohypogastric Nerves Combined with Gluing in Modified Lichtenstein Repair

We conducted a cohort trial to investigate the relevance of resection of the ilioinguinal and iliohypogastric nerves in combination with mesh fixation with BioGlue™ (CryoLife® Inc., Kennsaw, Georgia) in modified Lichtenstein repair to the development of chronic pain and hernia recurrence.1 In all, 430 patients underwent Lichtenstein repair. In 247 patients the mesh was fixed by means of glue, and in 183 patients it was fixed with conventional sutures. In all cases the inguinal nerves N. ilioinguinalis and N. iliohypogastricus were located and resected after identification to prevent nerve reaction to the mesh. The pain intensity was measured with a numeric analogous scale (NAS) 24 hours after surgery. All complications were recorded with a follow-up of up to 5 years. There was a significantly lower pain intensity level in the gluing group compared with the suture group 24 hours after surgery (0.016 t test). The level was 3.8±2.4 in bilateral hernia and 3.3±2.1 in unilateral hernia in the gluing group. It was 4.7±3.3 in unilateral and 3.7±2.2 in bilateral hernia in the suture group. The cut-suture time was lower in the gluing group. There were no severe pain syndromes (NAS≥4) in the gluing group and only 1.1% in the suture group. There was a higher incidence of non-bacterial wound infections in the gluing group (3.6%) than in the suture group (1.1%). The rate of recurrence after 5 years amounted to 2.0% in the gluing group and 2.2% in the suture group. The technique of using BioGlue™ for mesh fixation combined with systematic nerve dissection reduces acute and chronic postoperative pain after modified Lichtenstein repair. Only 2 of 430 patients suffered from severe chronic pain. Combined gluing and systematic resection of the inguinal nerves is more comfortable than standard Lichtenstein repair.

Thromboangiitis obliterans - case report

Thromboangiitis obliterans (Buerger'€™s disease) represents an inflammatory disease of limbs'€™ small arteries and veins causing vascular thrombosis, and partial or total obstruction. It affects mostly male gender aged 40 years old. The peculiarity of our case is underlined by presenting a 62 years, chronic tobacco user and not compliant female patient known with thromb oangiitisobliterans for almost 15 years. The arteriographic and clinical features with concomitant and sever affected upper and lower limbs are highly suggestive, emphasizing the possibility of Buerger'€™s disease development even in female patients.

The LION procedure to the pelvic nerves for treatment of urinary and faecal disorders

Bladder dysfunctions have been treated for decades through medical treatments or surgical procedures, especially in the context of prolapse conditions and stress incontinence. Over the last decade, sacral nerve modulation (SNM) has been introduced as a further option in the treatment of some urinary and fecal symptoms. Current techniques of percutaneous implantation are limited to superficial extrapelvic nerves that expose patients to lead migration and dislocation or infections, complications that cannot be ignored. Access to endopelvic nerves and plexuses will be mandatory in the future, especially to the sacral plexus area that is the crossroads of all vesical-sphincteric, anorectal, and sexual functions. The endopelvic location of electrodes protects against the above mentioned complications. Some open-surgical approaches have been described in the past, but all of them were extremely laborious and dangerous. All these limitations were overcome with the introduction of laparoscopy into the field of pelvic oncology. Laparoscopic retroperitoneal surgery and the development of video-endoscopy and appropriate instruments allows for access and visibility to all pelvic nerves and plexuses as well as laparoscopic pelvic neurosurgical procedures. One of these methods is the implantation of neuroprothesis-a technique called the "LION procedure"-which permits selective electrical stimulation of pelvic nerves and plexuses. One very interesting site of implantation for treatment of urinary and faecal symptoms is the pudendal nerve (PN). Stimulation of this nerve induces two different actions: a strong contraction of the sphincters-treatment of urinary and faecal incontinence and an inhibitory effect on the bladder-and treatment for bladder overactivity.

[A MRI study of lumbar plexus in patients with degenerative lumbar scoliosis after extreme lateral interbody fusion]

OBJECTIVE

To analyze the magnetic resonance neural imaging distribution of lumbar plexus in patients with degenerative lumbar scoliosis and evaluate its value and the safety of extreme lateral interbody fusion (XLIF).

METHODS

Three-dimensional fast imaging employing steady-state acquisition (3D FIESTA) sequences of lumbar spine were scanned on 19 patients with degenerative lumbar scoliosis, including levo scoliosis (n = 11) and dextro scoliosis (n = 8). All images were sent to workstation for multiplanar volume reconstruction to analyze the distribution of lumbar plexus from L1-2 to L4-5 level. The axial image distance (AID) was measured between anterior edge of lumbar plexus and sagittal central perpendicular line (SCPL). SCPL was drawn perpendicularly to the sagittal plane of intervertebral disc and passed through its central point. It was actually the pathway of guide wire implanting procedure and the ongoing axis of work channel during XLIF. With respect to SCPL, the distance with a positive value indicated posterior neural tissue whereas a negative value anterior neural tissue. The differences of AID were compared between convex and concave sides and among different cases and levels.

RESULTS

From L1-2 to L4-5 level, the AID on the concave side in levo scoliosis or dextro scoliosis cases was (13.7 ± 2.5) mm/ (12.9 ± 5.5) mm, (8.3 ± 4.7) mm/ (8.5 ± 5.7) mm, (2.7 ± 3.6) mm/ (2.5 ± 7.2) mm and (-4.2 ± 3.8) mm/ (-3.8 ± 7.1) mm respectively. They were located significantly posteriorly to the relevant disc compared to those on the convex side at the same intervertebral space (P < 0.05). The differences of AID at the same side, concave or convex side, was significant (P < 0.05). No significant differences of lumbar plexus distribution existed between levo scoliosis and dextro scoliosis cases (P > 0.05).

CONCLUSION

Lumbar plexus passes through psoas posteriorly to SCPL on both side at L1-2, L2-3 level and on the concave side at L3-4 level. And they shift anteriorly to SCPL on the convex side at L3-4 level and on both sides at L4-5 level. It indicates a ventral migration of lumbar plexus from L1-2 to L4-5 level. Preoperative magnetic resonance neural imaging is valuable for assessing the safety of XLIF approach. Operation from the concave may reduce the risk of injury to lumbar plexus.

Severe plantar hyperhidrosis: an effective surgical solution

Severe palmoplantar hyperhidrosis both affects activities of daily living and diminishes quality of life. This study evaluated overall safety and efficacy of endoscopic lumbar sympathectomy (ELS) using a clamping method in a large series of consecutive patients. Patient data were routinely entered into a prospectively designed database. Plantar sweating was graded as cured, improved, or unchanged. ELS (using 5-mm titanium clips) was performed in 154 patients, 68.2 per cent at the third lumbar vertebrae and 31.8 per cent at the fourth lumbar vertebrae. Follow-up averaged 15 months and ranged up to 4.7 years. Anhidrosis was achieved in 97.4 per cent of patients with the remainder reporting major reduction in symptoms. All patients were discharged home within 24 hours of surgery, requiring only oral analgesics, if any. There were two surgical complications (lymphatic leak and misidentification of genitofemoral nerve for sympathetic nerve). Six early patients required conversion to an open surgical procedure. Partial recurrence, usually mild, occurred in 4.5 per cent with 2.6 per cent requiring revision surgery. Severe plantar hyperhidrosis can be safely and effectively treated by endoscopic lumbar sympathectomy using the clamping method. It can be accomplished on an outpatient basis with low morbidity, complete resolution of symptoms, and a significant improvement in quality of life.

[Effect of iliolumbar fixation in patients with Tile C pelvic injury and analysis of relative factors]

OBJECTIVE

To explore the relative prognostic factors of Tile C pelvic injury after iliolumbar fixation.

METHODS

Between March 2007 and March 2010, 60 patients with Tile C pelvic injuries were surgically treated with iliolumbar fixation, including 39 males and 21 females with an average age of 37 years (range, 17-66 years). Of them, 27 cases were classified as Tile C1, 20 as Tile C2, and 13 as Tile C3. The preoperative injury severity score (ISS) was 12-66 (mean, 29.4). The time from injury to surgery was 2-25 days (mean, 8.1 days). Iliolumbar fixation was performed in all patients. Unconditional logistic analysis was used to analyze the relationship between the age, sex, body mass index (BMI), operation opportunity, the preoperative combined injury, classification of fracture, the postoperative complication, reduction outcome, sacral nerve injury, and the time of physical exercise and the prognosis.

RESULTS

All 60 patients were followed up 12-56 months (mean, 27.3 months). Infection of incisions occurred in 12 cases and were cured after dressing change; healing of incision by first intention was obtained in the other patients. Delay sacral nerve injury was found in 15 patients, 6 patients underwent nerve decompression, and 9 underwent conservative treatment. Ten patients had nail protrusion of Schanz screws at the posterior superior illac spine, and 3 patients had pain, which was relieved after removal of the internal fixator. One patient had bone-grafting nonunion of sacroiliac joint, which was improved by pressured bone graft. Five patients had the beam breakage without significant effect. Six patients had deep vein thrombosis, among them 4 underwent filter and 2 underwent nonsurgical treatment. The healing time of fracture was 3-6 months (mean, 3.9 months). According to the Matta function score, the results were excellent in 31 cases, good in 24 cases, fair in 3 cases, and poor in 2 cases with an excellent and good rate of 91.7% at last follow-up. Majeed score was 58-100 (mean, 86), 28 were rated as excellent, 12 as good, 16 as fair, and 4 as poor with an excellent and good rate of 66.7%. The logistic analysis showed that the age, sex, BMI, and postoperative complications were not prognostic factors; early operation (within 10 days), early function exercises (within 7 days), the better reduction quality, and the less sacral nerve injury were in favor of prognosis; and the worse preoperative combined injury and pelvic injury were, the worse the prognosis was.

CONCLUSION

Operation opportunity, the preoperative combined injury, reduction outcome, sacral nerve injury, and the time of physical exercise are all significantly prognostic factors of Tile C pelvic injuries.

[The efficiency of lumbar transperitoneal laparoscopic sympathectomy--100 cases revue]

Lumbar sympathectomy, classical surgical technique applied in conventional arteriopathy treatment, has acquired new valence by the development of laparoscopic technique. In a period of ten years (2000-2009), a number of 100 patients with different cause of arteriopathy have been operated by transperitoneal lumbar sympathectomy. Mean age was 62 years. Indication establishment has been achieved by an investigation protocol taking into account clinical and Para clinical criteria and methods. Postop evolution has been simple with very low morbidity and mortality zero. Particularly good evolution had patients in stages II and III of the disease, with missing effort claudication and repaos pain. Unfavourably results were recorded in advanced stages of disease, at diabetic patients with plenty of associated disease, therefore 9 patients suffering amputations of limbs. Results immediate and late were coordinated with stage and age of patients. Lumbar laparoscopic transperitoneal sympathectomy represents a viable alternative in artheriopathy treatment because of reduced morbidity--representing a chance for these very delicate patients.

A short postgraduate anatomy course may improve the junior surgical residents' anatomy knowledge for the nerves of the inguinal region

BACKGROUND AND AIM

Inguinal hernia repair is one of the most common operations in a junior surgical resident's postgraduate training. Short recall courses can improve junior residents' anatomy knowledge and results in better surgical outcomes. We aimed to investigate the effect of a short course on anatomical competency during inguinal hernia repairs.

METHODS

During the first 25 inguinal hernia repairs, two junior residents were asked to identify iliohypogastric, ilioinguinal, and genital branch of genitofemoral nerves. Then, the residents were given a short recall course by anatomists. Afterwards, the participants were taken into an in-vivo anatomy test again. The same parameters were recorded in another 25 inguinal hernia repairs. In addition to the nerve identification records, case characteristics [body mass index (BMI < or = 25 vs. >25), hernia type (indirect vs. direct), and anesthesia used (general or regional vs. local)] were recorded.

RESULTS

Anatomy education had a clear impact on the correct identification rates for the iliohypogastric and ilioinguinal nerves. The rates increased from 70% to 90% and above. Correct identification rate for the three nerves together significantly increased from 16 to 52% following anatomy education (P = 0.006). All three nerves were identified with significantly higher success rates after anatomy education. The increase in the success rate for identification of the genital branch of genitofemoral nerve was 4-fold.

CONCLUSIONS

Short anatomy courses in specific subjects for junior surgical residents given by formal anatomists may be effective during postgraduate education. The benefit obtained in the present study for the inguinal region nerves may be expanded to more important anatomical structures, such as the recurrent laryngeal nerve in a thyroidectomy, or more complex subjects.

Sacral neuromodulation in patients with multiple sclerosis

PURPOSE

We present a case series of patients with multiple sclerosis (MS) and neurogenic lower urinary tract dysfunction treated by sacral neuromodulation (SNM).

METHODS

We reviewed charts of 25 patients who were treated for refractory lower urinary tract symptoms; during the SNM testing phase, patient management included evaluation of number of daily voiding, number of episodes of incontinence, residual urine and quality of life score. Patients who experienced greater than 50% improvement in symptoms of frequency and incontinence episodes and/or a greater than 50% decrease in the number of catheterizations and a greater than 50% increase in voided volumes were offered placement of the permanent InterStim(TM) .

RESULTS

Fifteen patients were implanted with InterStim(TM); mean duration of MS was 13.66 years; mean follow-up of patients was 49.4 months. Nine patients were on clean intermittent catheterization, and in all of them, a significant decrease in residual volume with increase in voided volume and number of voiding per day; in 6 patients, the main problem was incontinence, and in them incontinence, episodes decreased and voided volume increased. Sixty-six per cent of patients have a functioning device after a mean follow-up of 61.2 months.

CONCLUSIONS

SNM is a good option in the treatment of voiding dysfunction in patients with MS in a medium to long-term follow-up. Urinary retention due to detrusor underactivity is not a good indication for SNM; it should be offered to MS patients with refractory urgency urinary incontinence and MS patients with urinary retention due to detrusor-sphincter dyssynergia (DSD).

[Surgical mistakes in treatment of patients with lower limbs' critical ischemia]

The immediate and long-term results of the operative treatment of 473 patients with lower limbs' critical ischemia were analyzed. The ischemia was caused by vascular damage under the level of Pupart ligament. All patients overcame direct and indirect surgical revascularization procedures. The results of the reconstructive operations depended directly upon the transplant permeability both in early and long-term periods. Thus, the shunt thrombosis by femoral-popliteal bypass above the popliteal joint space was 7.5-10.7%, not depending on the operative technique. Whereas, the shunt thrombosis by femoral-popliteal bypass below the popliteal joint space was 8.5-37.0%, directly depending on the operative technique. The thrombosis frequency after femoral-tibial bypass was in between 28.3-100.0%. The comparative analysis proved obvious advantages of direct and combined revascularisations.

[Application of robotic assistance in surgical treatment of degenerative disease of lumbosacral spine]

Robotic assistance has gained increasing popularity in spinal surgery recently. Robotic assistance provides higher effectiveness and safety especially in conditions of complicated anatomy. It also enables the novel, previously unavailable surgical techniques, such as GO-Lif for lumbar spine fusion. The aim of the study is to assess the applicability and effectiveness of the robotic assistance in surgical treatment of degenerative lesion of lumbar spine. 16 patients were operated with robotic assistance device (SpineAssist; MAZOR Surgical Technologies, Caesarea, Israel) between August 2009 and February 2010 in Spinal Department of Burdenko Neurosurgical Institute (Moscow, Russia) with degenerative disc disease. Preoperative assessment included MRI, X-rays and high-resolution CT (slice < 1 mm). The CT is essential for preoperative planning using computed work station SpineAssist. The robot was utilized for automated intraoperative positioning of the instruments according to preoperatively planned trajectories. Basic parameters of surgeries were thoroughly recorded: overall surgery time, radiation dose (all manipulations were performed under fluoroscopic control), accuracy of screw placement relative to preoperative planning, which was assessed using postoperative high-resolution CT with 3D reconstruction. Particular interest of the study was focused on the novel fusion technique for lumbar spine: Go-Lif (Guided Oblique Lumbar Interbody Fusion). This fusion modality enables segment fixation with two screws only, it is comparable with pedicular screws in terms of stability, being far less invasive. It may be used standalone or together with TLIF techniques. Robotic assistance enabled optimal screw placement even in complex anatomical cases (thin pedicles and rotational deformity). No implant-related complications were recorded. Surgery time was much longer in first 2 cases, though in further it decreased nearly to conventional (without robot) surgery time. For radiation dose same tendency was observed--in first 2 cases all surgical steps were fluoroscopically controlled, in further cases--only for primary anatomy registration. Based on control CT, accuracy of implant placement with robotic assistance is 1 mm.

New surgical evolutions in management of sacral radiculopathies

Neurophysiological investigations and neurosurgical procedures of the sacral plexus are not especially well developed, because the sacral plexus is difficult to access. Awareness that sacral radiculopathies may exist is still lacking and the incidence of these pathologies is widely underestimated. Since the recent introduction of laparoscopy in the field of pelvic nerves, the situation has changed considerably: laparoscopy not only permits a precise morphological and functional exploration of the entire sacral plexus, but also offers new therapeutic options: In lesions to the sacral nerve roots by compression, infiltration, or surgical damages, the laparoscopy offers an adequate access for micro-neurosurgical procedures; whereas in neurogenic pathologies or situations of failure of neurosurgical treatments, the technique of laparoscopic implantation of a neuroprosthesis - the LION procedure - permits the neuromodulation of all sacral nerve roots in different combination with only one electrode for simultaneous control of pelvic/lower limb pain and pelvic visceral dysfunctions. Regarding the dramatically increased incidence of sacral radiculopathies, especially secondary to pelvic prolaps surgeries by blind mesh-material implantation, this field of pathologies has to come in the focus of medical interests. Also, physicians involved in pelvic pathologies/surgeries have to be trained in clinical neuropelveology.

[The renaissance of lumbar sympathectomy]

The question addressed was whether the use of sympathectomy was of benefit in non-revascularisable critical leg ischaemia. Altogether 387 papers were found, of which 13 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that lumbar sympathectomy is a minimally invasive procedure with a low complication rate. Randomized controlled trials have failed to identify any objective benefits for lumbar sympathectomy, but subjective improvements in symptoms for patients with highly symptomatic critical leg ischaemia have been consistently demonstrated in multiple cohort studies with sustained symptom improvements in approximately 60% of patients. Lumbar sympathectomy is in process of renaissance and should be considered for symptomatic patients with critical leg ischaemia as an alternative to amputation in patients with otherwise viable limbs.

[Indications for lumbar sympathectomy and prognostication of its outcome in patients with obliterating atherosclerosis of the lower extremity arteries in chronic critical tissue ischemia]

Indications for lumbar sympathectomy performance in patients, suffering obliterating atherosclerosis with chronic critical ischemia, were substantiated. To prognosticate the operation result there were analyzed clinical data and data of instrumental investigation of 290 patients, permitting to estimate the state of macrohemodynamics (roentgencontrast arteriography, ultrasonic dopplerometry, rheova-sography) and microcirculation (laser Doppler's flowmetry--LDF). Initial indices of macro- and microhemodynamics on the foot are the important prognostication factors to predict the result of operation. Positive immediate postoperative results were achieved in 93.4% of patients, including 92.1%--while taking into account the macrohemodynamics indices and 96.4%--those, depicting the state of microcirculation.

Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency

Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy.

[Comparative assessment of methods used for predicting efficiency of lumbar sympathectomy in patients with lower-limb critical ischaemia]

The article deals with the findings of examination and treatment of patients presenting with lesions of the distal-bed arteries and critical lower-limb ischaemia who were subjected to lumbar sympathectomy (LSE). The methods aimed at predicting efficacy of LSE in seventy-five patiens included Doppler ultrasonography with the nitroglycerine test and with the epidural blockade. Of these forty-five patients were subjected to laser Doppler flowmetry (LDF) and measurement of the transcutaneous oxygen tension in tissues before and after the epidural blockade. Presented herein are remote results of LPE obtained at terms up to 36 months for sixty-nine patients (92%) and analyzed depending on the parameters of the functional tests. Our findings suggest that the most statistically significant methods of study for predicting the outcome of lumbar sympathectomy turned out to be LDF and Doppler ultrasonography performed before and after the epidural blockade.

From retroperitoneoscopic lumbar sympathectomy to total laparoscopic abdominal aorta surgery: how to learn

The aim of this report is to describe the steps we followed to build up laparoscopic experience progressively towards total laparoscopic aorta surgery. The techniques of retroperitoneoscopic lumbar sympathectomy, hand-assisted laparoscopic aorta surgery and total laparoscopic aorta surgery are discussed and illustrated. Surgical tips and tricks and advice concerning selection of patients and surgical techniques are proposed. The 30-day morbidity and mortality rates of laparoscopic, standard open and endovascular abdominal aorta aneurysm repair were compared.

Optimizing electrode implantation in sacral nerve stimulation--an anatomical cadaver study controlled by a laparoscopic camera

BACKGROUND AND AIM

Sacral nerve stimulation is the therapy of choice in patients with neurogenic faecal and urine incontinence, constipation and some pelvic pain syndromes. The aim of this study is to determine the best insertion angles of the electrode under laparoscopic visualization of the sacral nerves.

MATERIALS AND METHODS

Five fresh cadaver pelvises were dissected through an anterior approach of the presacral space, exposing the ventral sacral roots. Needles and electrodes were inserted into the S3 foramen. Both right and left sides were used, with the traditional percutaneous procedure. The validation was done by a laparoscopic camera controlling the position of the needle and electrode on the nerve. The angles were assessed with a goniometer and were confirmed in two living patients.

RESULTS

The mean angle of insertion in the sagittal plane was 62.9+/-3 degrees (range, 59-70). In the axial plane, the mean angle for the left side was 91.7+/-13.5 degrees (range, 80-110) and 83.2+/-7.7 degrees for the right side (range, 75-95). These angles resulted in the optimal placement of the leads along the S3 sacral root, in all these cases.

CONCLUSIONS

This study allows direct visualization during the placement of the needle and electrode, thus permitting accurate calculations of the best angle of approach during the surgical procedure in sacral nerve stimulation. These objective findings attempt to standardize this technique, which is often performed with the aid of intra-operative fluoroscopy but still leaving a lot to chance. These insertion angles should help to find more consistent and reproducible results and thus improved outcome in patients.

Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall

BACKGROUND

The aim of this study is to report on the feasibility of laparoscopic neurolysis of the plexus sacralis and the sciatic nerve in deep endometriotic infiltration of the lateral pelvic wall.

METHODS

A transperitoneal approach to the pelvic nerves combined with the LANN technique for intraoperative assessment of the function of the exposed nerves permit exposure and sparing of all somatic nerves during resection of the endometriotic lesion.

RESULTS

We report on our short experience with 21 patients who underwent this technique for the treatment of endometriotic infiltration of the sacral plexus at different levels.

CONCLUSION

In young patients with chronic unilateral sciatica or unilateral pudendal neuralgia - Alcock's canal syndrome - where no neurological/orthopedic etiologies have been found, endometriotic infiltration of the lateral pelvic wall has to be implicated as a potential etiology and an indication for laparoscopy must be discussed. Laparoscopic neurolysis of the pelvic somatic nerves is a feasible procedure for trained laparoscopic surgeons who have a good knowledge of the retroperitoneal pelvic (neuro)anatomy.

Resection of benign sciatic notch dumbbell-shaped tumors

OBJECT

The operative management of combined intrapelvic and extrapelvic sciatic notch dumbbell-shaped tumors is challenging. The relatively rare occurrence of these tumors and the varied extent of disease have made it difficult for surgeons to establish definitive surgical indications or predict favorable neurological outcomes based on preoperative imaging data.

METHODS

In the past 3 years, the authors treated five patients presenting with radiating leg pain as a result of benign sciatic notch dumbbell-shaped tumors. These tumors in three patients with unilateral leg symptoms were considered unresectable by other neurosurgeons because of presumed direct intrinsic neural involvement. After high-resolution magnetic resonance (MR) imaging demonstrated that the extensive tumors were separate from the sciatic nerve and the lumbosacral plexus, however, these patients underwent a combined one-stage transabdominal and posterior transgluteal complete resection. Normal neurological status was maintained postoperatively in these three patients, and after more than 1 year of postoperative follow up, there were no tumor recurrences. In two patients with bilateral symptoms and extensive tumor burden, serial MR images showed that innumerable tumors directly involved the entire cross-sectional area of the sciatic nerves and extended longitudinally to the lumbosacral plexuses. Tumor debulking or resection in these patients would have resulted in neurological deficits and would not have addressed their neuropathic pain, and therefore no surgery was performed. These two patients were treated pharmacologically and advised to monitor their tumor status over the course of their lifetimes in case of malignant transformation of the tumor.

CONCLUSIONS

A combined one-stage transabdominal and transgluteal approach allows safe resection of selected benign but extensive sciatic notch tumors. High-resolution MR imaging is a useful tool in the management of these tumors because it allows the surgeon to visualize the anatomical relationships of the tumor to the sciatic nerve. The authors believe that as this imaging technology advances, it will provide surgeons with a method to predict definitively which sciatic notch tumors displace rather than directly involve the sciatic nerve, and therefore indicate which tumors can be resected safely and completely.

Lumbosacral plexus lesions

BACKGROUND

Aim of the present study was to analyse the main causes of lumbosacral plexus lesions together with the best diagnostic and therapeutic options for better patient outcome.

METHODS

We report our surgical experience with eight patients in whom lesion mechanisms consisted of high-energy trauma (4 pts), firearm injuries (2 pts), spontaneous retroperitoneal haematoma in anticoagulant therapy (1 pt) and schwannoma (1 pt). The diagnosis was not straightforward and included clinical aspects, electrophysiological studies, magnetic resonance and CT myelography. Surgery was performed by lateral extraperitoneal approach for the lumbar plexus, transperitoneal approach on the midline to reach the sacral plexus, and neuronavigation was used in the schwannoma case.

CONCLUSIONS

Lumbosacral plexus lesions require a challenging multidisciplinary approach to diagnose and treat; the outcome, even if delayed, was very encouraging. In all our patients pain was controlled, and six patients returned to unaided walking.

Giant malignant nerve sheath tumor of lumbosacral plexus with intraspinal extension in a child with neurofibromatosis type 1

Malignant peripheral nerve sheath tumors (MPNSTs) are the leading cause of death in young adults and are one of the most frequent non-rhabdomyosarcomatous soft tissue tumors in pediatric age. These tumors usually occur in young adults from a previously recognized neurofibroma, neurofibromatosis type 1 (NF1), with a noted change in size and pain. This child reached the age of 10 without the presence of the more commonly seen manifestations of NF1. Pseudoarthrosis in children has a high rate of association with NF1, and in this case diagnosis of NF1 was supported by development of MPNST in a pre-existing plexiform neurofibroma.

Retroperitoneoscopic lumbar sympathectomy for nonreconstructable arterial occlusive disease

AIM

The aim of this study was to present our experience with video-assisted lumbar sympathectomy for non-reconstructive arterial occlusive disease in a series of 23 consecutive patients whose predominant symptoms were unilateral rest pain, limited skin ulcerations or gangrene of the toes.

METHODS

All the procedures were performed with retroperitoneal approach, dorsal position of the patient and simple digital dissection of the retroperitoneal space.

RESULTS

The operations were successfully performed in all patients except for 2, who immediately underwent open conversion. A urinoma caused by ureteral lesion was the only severe complication in this series. The mean operative time of the procedure was 55 min and the hospital stay was 2 or 3 days. No parenteral analgesics were administered postoperatively. At 1 month from operation, 20 patients out of 23 had significant relief of rest pain and improvement of ischemic lesions. After a median follow-up of 36 months, 2 patients had died, 4 underwent some type of distal amputation, 1 had recurrent rest pain and the other 16 reported persistent improvement of pain or dystrophic changes.

CONCLUSIONS

Retro-peritoneoscopic technique appears the modern and less invasive version of the lumbar surgical sympathectomy.

Ultrasound-Guided Lumbar Plexus Block for Open Reduction and Internal Fixation of Hip Fracture

PURPOSE

Ultrasound technology has been applied to increase both efficacy and safety of certain peripheral nerve blocks. This case report describes the first successful ultrasound-guided lumber plexus block.

CLINICAL FEATURES

We describe a 91-year-old woman with aortic stenosis who successfully underwent open reduction and internal fixation of a fractured right hip with a lumbar plexus block. Ultrasound provided direct visualization to help identify the anatomical structures and guide the block needle during performance of the block. Complete block of the lumbar plexus was attained within 15 min, and the surgical procedure was performed uneventfully.

CONCLUSION

The use of ultrasound has gained popularity to perform peripheral nerve blocks. In this case report, a successful lumbar plexus block was performed with ultrasound guidance. By direct visualization, using this technology may potentially reduce complications associated with lumbar plexus blocks.

Hypereosinophilic syndrome accompanying gangrene of the toes with peripheral arterial occlusion--a case report

The authors herein report the case of a teenage boy who presented with peripheral arterial occlusion of both upper and lower extremities associated with hypereosinophilia. During a 10-year follow-up, corticosteroid therapy was continued for the treatment of hypereosinophilia. The patient underwent bilateral lumbar sympathectomies because of severe ischemia of the bilateral lower extremities with gangrene of the toes. Based on the progress of his disease over the past 10 years, he was suspected to have idiopathic hypereosinophilic syndrome (HES) accompanied by peripheral arterial obstruction. Idiopathic HES is a disease characterized by unexpected hypereosinophilia, which may lead to organ damage. This is a very rare case of peripheral arterial occlusion associated with idiopathic HIS.

Trends in the Presentation and Surgical Management of the Acute Diabetic Foot

BACKGROUND

This study examines trends in the presentation and surgical management of acute diabetic foot problems in a single institution.

METHOD

Prospective audit of all diabetic patients who had a primary procedure for critical lower limb ischaemia (CLI) and/or foot sepsis between 1st January 1990 and 31st December 2002. Primary and secondary intervention, mortality and limb salvage rate within 6 weeks of the index procedure were recorded.

RESULTS

There were 661 patients (417 men and 244 women of median age 69, range 31-99, years) with 799 affected limbs. CLI alone was present in 625 (78%) limbs, combined CLI and foot sepsis in 53 (7%) and foot sepsis alone in 121 (15%). The primary intervention was minor amputation in 323 (40%) limbs, revascularisation in 288 (36%), major amputation in 185 (23%) and sympathectomy in three limbs. Within 6 weeks, 125 (16%) limbs required secondary intervention, the peri-procedural mortality rate was 38 of 924 (4%), and the limb salvage rates for patients with CLI, combined CLI and sepsis and sepsis alone were 66, 66 and 80%, respectively. There was a significant decline in the proportion of patients presenting with CLI alone and a significant increase in the proportion presenting with combined CLI and sepsis and sepsis alone. In patients with CLI alone, there was a significant increase in the primary major amputation rate and a significant decline in the minor amputation rate with no significant change in the revascularisation rate.

CONCLUSION

There has been a progressive decline in the proportion of patients presenting with CLI alone and a greater proportion of patients presenting with an element of foot sepsis. In patients with CLI alone, the primary major amputation rate has increased at the expense of a decline in minor amputation rate.

Muscle fibrillation as a sign of electrode damage in sacral neuromodulation

Sacral root neuromodulation is recognized as an effective therapy for chronic voiding dysfunction. However, knowledge about the neuromodulator in the general medical community is scarce. We report a case of muscle fibrillation caused by current leaking from a neuromodulator lead which had been damaged during disc prolapse surgery.

Anal sphincter reconstruction using a transposed gracilis muscle with a pudendal nerve anastomosis: a preliminary anatomic study

PURPOSE

Few studies have demonstrated the feasibility of cross innervating a skeletal muscle neosphincter with the pudendal nerve in an animal model. This study was designed to evaluate in humans the technical feasibility of anastomosing the nerve of the gracilis muscle and the pudendal nerve when the gracilis muscle is transposed around the anus.

METHODS

Anatomic assessment was made in 30 cases. The gracilis muscle and its principal neurovascular pedicle were dissected and the nerve to the gracilis divided at its origin. The gracilis muscle, accompanied by its nerve, was then transposed around the anus. The pudendal nerve was dissected in its extrapelvic portion and divided at its termination. Gracilis reinnervation was considered feasible when the proximal end of the nerve to the gracilis muscle and the distal end of the pudendal nerve were able to be placed into tension-free contact.

RESULTS

The mean lengths of the nerve to the gracilis and the pudendal nerve were 126.5 +/- 20.6 mm and 57.5 +/- 16.3 mm. Anastomosing the nerve of the gracilis muscle and the pudendal nerve was possible in 28 cases. There was a total mean surplus nerve length of 25.1 +/- 20.9 mm. In 26 cases, the distal end of the pudendal nerve (mean, 3.3 +/- 1.1 mm) was similar or larger than the end of the nerve to the gracilis (mean, 3 +/- 0.8 mm).

CONCLUSIONS

Anal sphincter reconstruction using transposed gracilis muscle with pudendal nerve anastomosis is anatomically achievable in cadavers, and supports the potential applications of this technique for perineal reconstruction in clinical practice.