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Neuropathy may cause fecal incontinence and mixed fecal incontinence/constipation, but its prevalence is unclear, partly due to the lack of comprehensive testing of spino-anorectal innervation.This study aimed to develop and determine the clinical usefulness of a novel test, translumbosacral anorectal magnetic stimulation for fecal incontinence.This observational cohort study was conducted from 2012 to 2018.This study was performed at a tertiary referral center.Patients with fecal incontinence, patients with mixed fecal incontinence/constipation, and healthy controls were included.A translumbosacral anorectal magnetic stimulation test was performed by using an anorectal probe with 4 ring electrodes and magnetic coil, and by stimulating bilateral lumbar and sacral plexuses, uses and recording 8 motor-evoked potentials at anal and rectal sites.The prevalence of lumbar and/or sacral neuropathy was examined. Secondary outcomes were correlation of neuropathy with anorectal sensorimotor function(s) and morphological changes.We evaluated 220 patients: 144 with fecal incontinence, 76 with mixed fecal incontinence/constipation, and 31 healthy controls. All 8 lumbar and sacral motor-evoked potential latencies were significantly prolonged (p0.01) in fecal incontinence and mixed fecal incontinence/constipation groups compared with controls. Neuropathy was patchy and involved 4.0 (3.0) (median (interquartile range)) sites. Lumbar neuropathy was seen in 29% to 65% of the patients in the fecal incontinence group and 22% to 61% of the patients in the mixed fecal incontinence/constipation group, and sacral neuropathy was seen in 24% to 64% and 29% to 61% of these patients. Anal neuropathy was significantly more (p0.001) prevalent than rectal neuropathy in both groups. There was no correlation between motor-evoked potential latencies and anal sphincter pressures, rectal sensation, or anal sphincter defects.No comparative analysis with electromyography was performed.Lumbar or sacral plexus neuropathy was detected in 40% to 75% of patients with fecal incontinence with a 2-fold greater prevalence at the anal region than the rectum. Lumbosacral neuropathy appears to be an independent mechanism in the pathogenesis of fecal incontinence, unassociated with other sensorimotor dysfunctions. Translumbosacral anorectal magnetic stimulation has a high yield and is a safe and clinically useful neurophysiological test. See Video Abstract at http://links.lww.com/DCR/B728.ANTECEDENTES:La neuropatía puede causar incontinencia fecal y una combinación de incontinencia fe-cal/estreñimiento, pero su prevalencia no está clara, en parte debido a la falta de pruebas comple-tas de inervación espino-anorrectal.OBJETIVO:Desarrollar y determinar la utilidad clínica de una nueva prueba, estimulación magnética trans-lumbosacral anorrectal para la incontinencia fecal.DISEÑO:Estudio de cohorte observacional del 2012 al 2018.ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes con incontinencia fecal, combinación de incontinencia fecal/estreñimiento y controles sanos.INTERVENCIONES:Se realizó una prueba de estimulación magnética translumbosacral anorrectal utilizando una sonda anorrectal con 4 electrodos anulares y bobina magnética, y estimulando los plexos lumbares y sacros bilaterales y registrando ocho potenciales evocados motores las regiones anal y rectal.PRINCIPALES MEDIDAS DE RESULTADO:Se examinó la prevalencia de neuropatía lumbar y/o sacra. Los resultados secundarios fueron la correlación de la neuropatía con las funciones sensitivomotoras anorrectales y cambios morfológi-cos.RESULTADOS:Evaluamos 220 pacientes, 144 con incontinencia fecal, 76 con combinación de incontinencia fe-cal/estreñimiento y 31 sujetos sanos. Las ocho latencias de los potenciales evocadas motoras lum-bares y sacras se prolongaron significativamente (p0,01) en la incontinencia fecal y el grupo mixto en comparación con los controles. La neuropatía fue irregular y afectaba 4,0 (3,0) (mediana (rango intercuartílico) sitios. Se observó neuropatía lumbar en 29-65% en la incontinencia fecal y 22-61% en el grupo mixto, y neuropatía sacra en 24-64% y 29-61 % de pacientes respectivamen-te. La neuropatía anal fue significativamente más prevalente (p0,001) que la rectal en ambos grupos. No hubo correlación entre las latencias de los potenciales evocadas motoras y las presio-nes del esfínter anal, la sensación rectal o los defectos del esfínter anal.LIMITACIONES:Sin análisis comparativo con electromiografía.CONCLUSIÓNES:Se detectó neuropatía del plexo lumbar o sacro en el 40-75% de los pacientes con incontinencia fecal con una prevalencia dos veces mayor en la región anal que en el recto. La neuropatía lumbo-sacra parece ser un mecanismo independiente en la patogenia de la incontinencia fecal, no asocia-do con otras disfunciones sensitivomotoras. La estimulación magnética translumbosacral anorrec-tal tiene un alto rendimiento, es una prueba neurofisiológica segura y clínicamente útil. Consulte Video Resumen en http://links.lww.com/DCR/B728.

Objective. The study aimed to explore the application of ultrasound image-guided general drug anesthesia combined with lumbar and sacral plexus block based on MATrix LABoratory (MATLAB) algorithm in hip arthroplasty and to study its clinical effect. Methods. The classic geodesic active contour (GAC) algorithm and the improved fuzzy clustering level set algorithm were used to segment ultrasound images of waist plexus, and then their segmentation effects were compared. Both algorithms are from the MATrix LABoratory (MATLAB) platform. A total of 60 patients undergoing hip arthroplasty were selected and randomly enrolled into control and experimental groups. The control group accepted general drug anesthesia, and the experimental group accepted ultrasound-guided lumbar and sacral plexus block combined with general anesthesia. The mean arterial pressure and heart rate at t0 (before anesthesia), t1 (before ventilation), t2 (when the skin was incised), t3 (when the prosthesis was implanted), t4 (when the incision was closed), and t5 (at the end of ventilation) were observed, and the intraoperative sufentanil dosage and 24 h analgesic dosage, the incidence of postoperative delirium, and the incidence of cognitive dysfunction were recorded. Results. The improved fuzzy clustering level set algorithm was better than the GAC model algorithm in image segmentation and running time. In contrast with the control group, the average arterial pressure and heart rate of the experimental group at the four time points of t1, t2, t3, and t5 were obviously reduced ( P P P

Sciatic nerve symptomatology may arise from both intra- and extra-neural pathology, at any point along descent from the sacral plexus to its bifurcation. The potential aetiology is broad, ranging from degenerative spinal disease to muscle, bony and vascular pathology. We present an extremely unusual case of position and exercise-induced nerve compression secondary to arteriovenous malformation and review the potential extraspinal causes, many of which may be ameliorated by surgical excision or decompression. We further discuss the usefulness of diagnostic imaging, specific clinical tests and histopathological tools that may aid in management.

Objective: To report on diagnosis and management of pelvic congestion including the May-Thurner syndrome (MTS) as potential etiologies for intractable pelvic neuropathic pain. Design: Retrospective study of women presented with intractable pelvic neuropathic pain, who had left sided venous uterine plexus above 6mm with reversed and slow flow on Doppler, with dilated arcuate veins passing through the uterine muscle. Those with suspicion of MTS underwent further radiological investigations and if applicable, endovascular interventions. Setting: Tertiary referral unit specialized in advanced gynaecological surgery and neuropelveology. Intervention: 61 consecutive patients were included. 14 with visceral pain presumed to be caused by Pelvic Congestion Syndrome were treated by ovarian vein embolization. An improvement of pain was observed in all patients – mean pain reduction of 3.93 points, from 7.21 (±1.42; 4-10) to 3.28 pts (±1.54; 1-6) over 6 months (p

The pelvic autonomic nerves control and regulate anorectal and urogenital function. The dysfunction of pelvic autonomic nerves lead to disorders of anorectum, bladder and male sex organs. Thus the intraoperative identification of pelvic autonomic nerves could be crucial in complications prevention and diseases treatment. Our clinical trial aims at estimating the effectiveness and validity of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves identification. Intraoperative fluorescence imaging using indocyanine green was performed in ten patients and the feasibility was determined. From February 2019 to June 2019, the seven patients undergoing laparoscopic colorectal resection was administrated 4.5 mg/Kg indocyanine green 24 h before surgery. The near-infrared fluorescence imaging was conducted during surgery. A novel white light and near-infrared dual-channel laparoscopic equipment was applied. For each patient, signal–background ratio values for pelvic autonomic nerves were recorded and analyzed. We confirmed the dose and timing of indocyanine green administration was 4.5 mg/Kg and 24 h before surgery. Using the dual laparoscopic equipment, we could observe the splanchnic plexus, inferior mesenteric artery plexus, and sacral plexus successfully with a high signal background ratio value of 3.18 (standard deviation: 0.48). This pilot trial shows feasibility of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves observation. It demonstrates that nerves can be visualized using alternative imaging techniques but it is not ready yet for prime time. This technique might aid observation with white light alone. Registration number: ChiCTR1900025336.

Introduction Lateral pelvic recurrence can be a cause of local failure after surgery for low rectal cancer. Lateral lymph node dissection is often performed in East Asia for patients with enlarged lateral lymph nodes or because of the presence of risk factors. However, the outcomes of the conventional lateral lymph node dissection are unsatisfactory, with a considerably high local recurrence rate for patients with positive lateral nodes. Here, we introduce a modified technique to improve lateral nodes clearance. Technique This modified technique has 4 key steps: 1) separation of the ureterohypogastric nerve fascia medially, 2) identification of the visceral pelvic fascia and dissection along the inferior vesical or vaginal veins down to the pelvic floor, 3) division of the distal ends of visceral vessels according to the orientation of ureterohypogastric nerve fascia and visceral pelvic fascia for better nerve preservation, and 4) en bloc dissection through a lateral approach over the surfaces of the sacral plexus and piriformis muscle to reveal the course of distal internal iliac vessels before the division of visceral veins. Results Twenty-nine patients underwent laparoscopic lateral lymph node dissection successively with no conversion. The median blood loss for each lateral procedure was 37.5 mL (range, 0-300.0 mL). Eleven lateral nodes (median; range, 1-22 lateral nodes) were harvested for each lateral side. There was no perioperative mortality, and 4 patients developed major complications (Clavien-Dindo III-IV). Conclusion This modified technique characterized by the routine division of visceral vessels based on ureterohypogastric nerve fascia and visceral pelvic fascia is feasible and safe. It provides good lymph node harvest, autonomic nerve preservation, and improved bleeding control. Additional investigation is warranted to evaluate the safety, functional outcomes, and oncologic outcomes.

Background: Peripheral block techniques for total hip arthroplasty have been used as an analgesic strategy, only a few studies described it as an anesthetic technique, so the perioperative performance and safety are poorly studied. Methods: 78 total hip arthroplasties were prospectively observed in our hospital. Divided into 2 groups: 1) General anesthesia; and 2) Lumbar sacral plexus block anesthesia. Variables measured in both groups were: demographics, conversion to general anesthesia, total opioid doses, surgical time, blood loss, postoperative pain, use and total dose of vasopressors drugs, transfusion and ICU transfer needs, postoperative ambulation time, and length of hospital stay. T student and chi-square tests were used upon the case. A significant difference was considered when a value of p Results: 3 patients (7.3%) anesthetized with combined lumbar sacral plexus block were converted to general anesthesia. When comparing peripheral nerve block and general anesthesia, less intraoperative (p = 0.000) and postoperative (p = 0.002) opioid consumption were noted, less postoperative pain in PACU (p = 0.002) and in the first 24 hours (p = 0.005), as well as earlier onset of ambulation (p = 0.008) and shorter hospital stay (p = 0.031). Conclusions: In our study, the lumbar and sacral plexus block anesthesia technique provided anesthetic conditions to perform hip joint arthroplasty and it was proved to be advantageous in comparison to general anesthesia.

The study was conducted for the determination of the main nerves of the lumbosacral plexus in the helmeted guineafowl. Five helmeted guineafowls were used. Fowls were anaesthetised and the a. carotis communis was cut for blood drainage. Body cavities were revealed and were fixated with 10% formaldehyde. Nerves forming the lumbosacral plexus were dissected and photographed. Results were named according to the Nomina Anatomica Avium. It was determined that the lumbosacral plexus forms by 8 synsacral ventral rami from the ventrolateral side of synsacrum which include (2-9) synsacral spinal nerves. It was seen that the lumbar plexus was formed by the ventral rami of the 2nd, 3rd and 4th spinal nerves, and the sacral plexus was formed by the ventral rami of the 5th, 6th, 7th, 8th and 9th synsacral spinal nerves. It was observed that following nerves of n. pubicus (ilioinguinalis), r. cutaneous femoris lateralis, r. cutaneous femoris medialis (n. saphenus), n. femoralis and n. obturatorius originate from the lumbar plexus, and following nerves of n. ischiadicus, the common branch of n. fibularis and n. tibialis originate from the sacral plexus. It was determined that the n. ischiadicus was formed by the truncus cranialis, medianus and caudalis. In conclusion, it was determined that there are macro anatomical differences between different avian species in the quantity, thickness and distribution of the spinal nerves that form the lumbosacral plexus, and in formations of the plexus, and in separations of nerve branches.

The approach to the sciatic plexus and lateral part of the sacrum is difficult. A subperitoneal anterolateral approach can be extended by sectioning the iliac bone above the acetabulum and lowering it toward the external part of the iliac wing and buttock. This transiliac anterolateral approach exposes the lumbosacral trunk, first sacral foramina and sciatic plexus to the origin of the sciatic trunk. Exposure can be extended upward by subperitoneal lumbotomy, downward by opening the ischiorectal fossa, or outward by trochanterotomy. This approach was used 18 times by one of the authors (FHD) for resection of 13 malignant tumors and 5 plexus releases. Procedure time was 3-6hours, with 500-4,000ml blood loss. The approach systematically enabled surgical objectives to be met. There was 1 septic complication that healed after debridement.

It was widely recognized that the procedure of ultrasound-guided lumbar and sacral plexus block is required to be performed in a lateral decubitus position that patients' hips and knees were bended. It is difficult, however, for patients with hip fractures to change position because of severe pain and confined movements. We here reported a new modified combination of ultrasound-guided lumbosacral plexus block with anterior quadratus lumborum block in supine position that had been successfully applied in one elderly patient who underwent hip surgery.

Introduction In cases of sacral nerve avulsion injuries, proximal nerve stumps are not available because of its protected position in pelvis, and results of nerve repair or graft are unsatisfactory. Nerve transfer can reduce the regeneration time and improve the results of recovery. Hypothesis The obturator nerve transfer to the tibial nerve via saphenous nerve graft is possible and feasible. Materials and methods Ten male adult cadaveric lower limbs dissected to identify the location of the anterior branch of obturator nerve, the saphenous nerve and the medial gastrocnemius branch. The saphenous nerve was cut from its origin and transferred to the anterior branch of obturator nerve. As well, it was cut distally and transferred to the medial gastrocnemius branch. After nerve coaptation, surface area and fascicle count were determined by histological methods. Results In all limbs, the proximal and distal stumps of saphenous nerve were reached the anterior branch of obturator and the medial gastrocnemius branch, respectively without tension. The mean of fascicle number in the anterior branch of obturator nerve, proximal and distal stump of the saphenous nerve and stump of medial gastrocnemius nerve branch were 2.90 ± 0.99, 4.50 ± 2.70, 4.00 ± 2.26 and 4.30 ± 1.25, respectively. Discussion This study showed that it is possible to transfer the obturator nerve to the medial gastrocnemius branch via saphenous nerve bridge; and their histological parameters are match in a good manner. Therefore, this technique is suggested for patients with sacral nerve avulsion injuries. Level of evidence IV, case series of cadaveric study.

Introduction Neurogenic bladder with anorectal malformations (ARM) is a well-known yet understudied topic. Diffusion tensor imaging (DTI) is a special usage of MRI that can evaluate peripheric nerves. The aim of this study is to evaluate the lumbosacral plexuses of patients with ARM using DTI. Patients and methods Patients with ARM willing to participate were included. Patient files were reviewed, a questionnaire was made, and DTI was performed. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were computed for the right and left lumbosacral plexuses. Results There were 18 patients and 12 controls. Groups were similar in terms of sex (p = 0.232) and age (p = 0.853). There was a significant difference only for ADC of the left plexus. There was visible asymmetry in tractographies and DTI parameters of two patients with severely deformed pelvises (image 1) but also in another patient with a normal sacrum. In addition, despite asymmetry, FA and ADC were similar to controls also in these patients. Conclusion This is the first study presenting quantitative data about the lumbosacral plexus in ARM. We think the most interesting finding of this study was observing the normal values even in the patients with severely malformed sacrum which is yet to be validated with further studies., Aliye Uster Foundation (Izmir, Turkey) research scholarship; research activities in Ege University, This work was supported by Aliye Uster Foundation (Izmir, Turkey) research scholarship. This is an independent organization funding educational and research activities in Ege University. The authors have no conflict of interest regarding the study.

Variations in the course of the lumbar plexus and lumbosacral trunk have been explored with respect to variant nerve roots being indicated in atypical sciatic pain. Typically, the furcal nerve emerges from the L4 nerve root, with a single contribution. However, we report a case where the furcal nerve was found to arise not only from the L4 nerve but also from the obturator nerve. This anatomical variation is explored in terms of its clinical significance and implications in lumbar and sacral plexus associated procedures.

Background: Ultrasound guided peripheral nerve blocks have become increasingly popular in the lower limb orthopaedic and gaining more acceptances in total hip replacement surger­ies too. The main objective of this study was to compare peripheral nerve block and spinal anesthesia for total hip replacement surgeries. Methods: In this retrospective study, total patients that underwent total hip replacement in our institution during specific time period were included for the study. They were divided into spinal and peripheral nerve block groups, and data were collected for the analysis. USG guided lumbar plexus, sacral plexus, superior gluteal nerve block was done and conventional landmark technique was done for spinal group. Mean arterial blood pressure, total fluid con­sumption, total fentanyl consumption, pain scores and incidence of nausea was compared. Results: We included 43 patients for the study in which 23 patients were included in nerve block group, and 20 patients in the spinal group. In compared to spinal group, nerve block group had more stable mean arterial blood pressure (P

Background: The SIOPE-Brain Tumor Group recently published a guideline on craniospinal target volume delineation for highly conformal radiotherapy. In order to spare critical structures like e.g., the lens or cochlea, highly conformal techniques can underdose the cerebrospinal fluid (CSF) in the dural reflections around cranial and sacral nerves. The purpose of this study is to generate evidence for CSF extension within the dural sheaths of the cranial and sacral nerves in order to improve accuracy in target volume delineation. Material and methods: Ten healthy volunteers, age 21 till 41 years, underwent an MRI-scan of the skull-base and sacral plexus. To evaluate CSF extension, cT2-weighted images with fat suppression, low signal to noise ratio and little to no motion-related artifacts were used. Two observers measured the extension of CSF from the inner table of the skull for the cranial nerves, and outside the spinal canal for the sacral nerves. Results: CSF extension (mean distance [95% CI]) was visible within the dural sheaths surrounding the majority of the cranial nerves: optic nerve (40 mm [38–42]), trigeminal nerve (16 mm [15–19]), facial-vestibulocochlear nerve (11 mm [11–12]), glossopharyngeal-vagus-accessory nerve (7 mm [7–9]) and hypoglossal nerve (8 mm [7–9]). No CSF was observed outside the spinal canal at sacral level. No significant difference between both observers was measured. Conclusion: This study generates evidence for significant CSF extension outside the inner table of the skull. Despite the vicinity of the lens and cochlea, we therefore recommend the inclusion of both optic nerves and internal auditory canals in the clinical target volume for craniospinal irradiation when using highly conformal delivery techniques.

Wir beschreiben erstmals ein Schwannom des N. gluteus inferior (NGI) bei einem 43-jahrigen Mann als Ursache fur gluteal ausstrahlende chronische Ruckenschmerzen. Nach monatelanger erfolgloser Diagnostik und Schmerztherapie mit Arbeitsunfahigkeit fuhrte erst eine zielgerichtete Sonografie der parasakralen Region zur Diagnose. Es zeigte sich eine hypoechogene Raumforderung im Verlauf des NGI. Es erfolgte die Tumorresektion mit histologischem Nachweis eines Schwannoms. Nach Resektion ist der Patient seit 15 Monaten ohne Medikation beschwerdefrei und wieder vollstandig in sein Berufsleben integriert.

Postpartum anal incontinence is a complex disorder that develops mainly in young women and negatively affects their social and professional activity. The aim of this review is to summarize the available literature and current concepts on the etiology, pathogenesis, diagnosis and treatment of postpartum anal incontinence. The prevalence of postpartum anal incontinence varies from 13 to 39 %. The risk factors include vaginal delivery, the use of instrumental methods, age, body mass index > 30, delivery-associated perineal tears, incontinence during pregnancy and smoking. The role of episiotomy in anal incontinence is not clear, some authors note a high risk of median episiotomy compared with mid-lateral one. Diagnosis of anal incontinence is mainly based on clinical examination and history data. The most informative imaging modality is endoanal ultrasound. Treatment of anal incontinence should begin with diet correction and medications for stool control. The efficacy of various treatment programs directed to strengthening the pelvic floor and anal sphincter muscles is controversial and needs further study. Surgical treatment is indicated if the conservative therapy is unsuccessful; the most common methods are sphincteroplasty and electroneuromodulation of the sacral plexus branches. Primary prevention measures for postpartum anal incontinence should focus on eliminating or reducing the risk factors. Special training programs for obstetricians can significantly reduce the number of perineal tears and their severity, as well as reduce the need in obstetric forceps. Secondary prevention steps include the correct choice of the first and subsequent deliveries in women with an increased risk.

Deep infiltrating endometriosis (DIE) is a particular form of endometriosis causing a variety of severe pelvic pain in women. The involvement of peripheral nerves by DIE implants is very rare. The most common involved site is the sacral plexus. There are few reported cases of involvement of the obturator nerve by DIE. To our knowledge, only 6 cases of symptomatic obturator nerve involvement by DIE have been described (according to PubMed database search in July 2018), and 3 of them were treated laparoscopically. We report a rare case of a deep infiltrating endometriotic nodule entrapping the right obturator nerve. Unlike the previously reported cases, patient history, clinical and laboratory data, and missed findings in previous imaging studies made our case difficult to diagnose. We successfully diagnosed the case and treated the patient with laparoscopic surgery. A video showing the surgery is also included. The recent follow-up in July 2018 (18 months after the operation was performed in January 2017) showed no signs or symptoms of recurrence or any other new complaints. The 18-month follow-up for this case is the longest follow-up data reported in the literature.

The neural plexus exists in different parts of the body. The sacral plexus is the lowest neural network in the body that is responsible for sensory and motor innervation to a large part of the body. The sacral plexus or sacral nerve roots may be damaged by diseases, such as disc herniation, spinal canal stenosis, and cancer or iatrogenic injuries during surgery or interventional pain procedures (open spinal surgeries, hip surgeries, percutaneous endoscopic disc decompression, trans-sacral epiduroscopic laser decompression, …). Patients with sacral nerve damage may experience a variety of symptoms, including low back pain radiating to the legs, sensory disturbance in the buttocks or legs, motor weakness in the legs, bladder or bowel dysfunction (urinary retention/incontinence, defecation’s problems), or sexual dysfunction. Therefore, complete familiarity with the anatomy of the sacral plexus is very important. In this article, we tried to review the anatomy of the sacral plexus and sensory or motor innervations of each terminal branch of the sacral plexus. Also, the clinical importance of these nerves in the development of pain syndromes and diagnostic and therapeutic methods for damage to the terminal branches of the sacral plexus were investigated.

Background Ultrasound-guided posterior lumbar plexus block is widely used for hip fracture surgery but it requires a change of position, which may be painful. Objectives Our primary objective was to describe a new technique, the anterior iliopsoas muscle space block, which can be performed in the supine position, and to test the hypothesis that its analgesia for hip surgery was similar to that of the traditional posterior lumbar plexus block. Design Randomised, double-blind study. Setting Shanghai 6th People's Hospital, China, from February to August 2019. Patients Forty-eight patients scheduled for unilateral hip fracture surgery were included in the study. The exclusion criteria were infection at the puncture site, history of hip surgery, pre-existing neurological deficits of the lower extremity, contraindications for regional anaesthesia, allergy to local anaesthetics, coagulopathy, abuse of medicine or alcohol, or daily consumption of analgesics. Interventions Patients were randomised to receive a lateral sacral plexus block with either an anterior iliopsoas muscle space block or a posterior lumbar plexus block, using 0.33% ropivacaine (30 ml each). Main outcome measures The main outcome was verbal numerical scale (VNS) pain intensity 1 h after surgery in the postanesthesia care unit, and the secondary outcome was the dose of intra-operative fentanyl. The differences in VNS scores and fentanyl use between the groups were analysed. Results Based on previous work, we considered a difference (confidence interval [CI]) of 1.6 on the VNS to be significant. The median [IQR] pain scores in postanesthesia care unit were similar in the anterior 0 [0 to 3] and posterior groups 1.5 [0 to 3]. The median scores for intra-operative fentanyl use were similar in the anterior 20 [10 to 42.5] μg and posterior groups 15 [0 to 50] μg (P = 0.34). The difference in the median pain score at-rest was NS: anterior group 0.5 [0 to 5], posterior group 0 [0 to 2], median difference -0.5 (95% CI -2 to 0). The median post to preblock difference in VNS was higher in the anterior -0.5 [-2 to 0] than in the posterior group 0 [-1.25 to 0], median difference 0.5 (95% CI 0 to 1). The median block onset time was longer in the anterior 11 [6 to 14.25] min than in the posterior group 6 [4.75 to 8] min (P = 0.002), median difference -5 (95% CI -7 to -1). Conclusion The anterior iliopsoas muscle space block had the same effect as the posterior lumbar plexus block on peri-operative analgesia for hip surgery, but with a longer onset time. Therefore, anterior iliopsoas muscle space block can be recommended as a routine technique for hip and lower limb procedures. Trial registration http://www.chictr.org.cn identifier: ChiCTR1900021214.

The inferior gluteal nerve (IGN) is a component of the sacral plexus and innervates the gluteus maximus muscle. The primary role of this muscle is in extension and lateral rotation of the hip. This chapter is dedicated to the detailed anatomy of the IGN and its pathology.

Although not part of the sacral plexus, knowledge of the pelvic splanchnic nerves is relevant to any discussion on t1he latter. This chapter details the anatomy, development, and function of the pelvic splanchnic nerves.

It is beneficial to have knowledge of the nerves derived from this plexus as well as knowledge of its anatomy. In fact, interpretation of sacral plexopathies' signs and symptoms requires clinical physicians to be familiar with this plexus' anatomy, as it can help the clinician localize the area of involvement and informs the diagnostic and therapeutic procedures necessary.

This chapter outlines the microanatomy of nervous structures that form the sacral plexus, including nerve roots found at vertebral levels extending from L4, L5, S1, S2, S3, and S4.

The posterior femoral cutaneous nerve is an important branch of the sacral plexus. Herein, its anatomy and pathological involvement are discussed.

The aim of the present study is to reveal the anatomical structure of lumbosacral plexus of barn owl. Six barn owls were included in the study. Nerves originating from plexus were dissected individually, and findings of innervation areas of nerves were determined. Lumbosacral plexus of barn owl was observed to be formed by ventral rami of ten synsacral spinal nerves. It was found that while the r. cutaneus femoris lateralis, the n. obturatorius, the n. coxalis cranialis, the r. cutaneus femoris medialis, the n. cutaneus femoris cranialis and the n. femoralis originated from the lumbar plexus, the n. isciofemoralis, the n. cutaneus femoris caudalis, the n. coxalis caudalis and the n. ischiadicus originated from the sacral plexus. Consequently, when the results of the study were compared with information of different avian species, it was observed that differences focused on the formation of the lumbar and sacral plexuses and innervation level of digits.

The nerve to quadratus femoris is only briefly mentioned in the literature. This nerve of the sacral plexus innervates two small muscles of the gluteal region but importantly, innervates the hip joint. Therefore, knowledge of its anatomy is important for denervation procedures. This chapter discusses the anatomy and pathology of the nerve to quadratus femoris.

This chapter outlines the microanatomy of nervous structures that form the sacral plexus, including nerve roots found at vertebral levels extending from L4, L5, S1, S2, S3, and S4.

The branches of the sacral plexus should be known to those who treat patients with diseases involving it or those interpreting imaging of its branches. This chapter details the anatomy and function of the nerve to levator ani.

The pudendal nerve is a paired nerve formed from the sacral plexus, which is a network of nerve fibers located in the posterior pelvic wall. It carries sensory, motor, and autonomic fibers, innervating the skin and muscles of the perineum. This chapter details this nerve's anatomy and pathology including variations.

Reading magnetic resonance neurography (MRN) of the sacral plexus is challenging owing to the complicated anatomy of the pelvis and to the small caliber and complex course of many nerves in this region. Although MRN can identify the roots of the sacral plexus and its tributaries, this examination remains difficult to perform and requires competence, high-resolution sequences, and a deep knowledge of the normal imaging anatomy. The aim of this chapter is to provide a comprehensive review of the imaging anatomy of the sacral plexus to help in interpreting MRN images correctly. We will describe the anatomy on MRN of the lumbosacral trunk, first to fourth sacral nerve roots, superior and inferior gluteal nerves, sciatic nerve, lateral femoral cutaneous nerve, peroneal nerve, tibial nerve, and pudendal nerve.

Most international learned institutions consider the etiology of “idiopathic” chronic pelvic pain, pain of no obvious cause, unknown and, therefore, not curable. The integral theory hypothesizes that CPP where no obvious cause is evident is mainly caused by inability of loose uterosacral ligaments (USLs) to support T11-L2 and S2-4 nerve plexuses contained within them. This type of CPP generally co-occurs with one or more symptoms of bladder and bowel dysfunctions. Data is presented to demonstrate that CPP and these symptoms can be improved with a squatting-based pelvic floor regime and potentially curable surgically by reinforcing uterosacral ligaments. A fundamental concept is that pain and associated symptoms may occur with even minimal apical prolapse.

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. 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. 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. 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.

Ultrasound guidance technique currently represents the gold standard for regional anesthesia. In particular for lower extremity blocks, compared to anatomical landmark or localization technique with nerve stimulation, the ultrasound technique shows a modest improvement in block onset and quality. However, current literature lacks large size randomized trials and heterogeneity exist in various blocks. This chapter aims to present a comprehensive review of relevant applied anatomy of lower extremity, anatomical, and ultrasound-guided techniques for each block, and clinical implications of most commonly performed lower extremity blocks.

Study Objective To assess 1-year postoperative outcomes of surgery for deep endometriosis involving the sacral roots and sciatic nerve. Design Retrospective case series. Setting Three referral centers. Patients Fifty-two women. Interventions Surgery for deep endometriosis involving the sacral roots and sciatic nerve. Measurements and Main Results Deep endometriosis involved the sacral roots in 49 women (94.2%) and the sciatic nerve in 3 cases (5.8%). Sciatic pain (buttock or leg) was recorded in 43 women (82.7%), pudendal neuralgia in 11 women (21.2%), and leg motor weakness in 14 cases (27%). The surgical procedures carried out on the pelvic nerves included complete release and decompression (92.3%), excision of the epineurium by shaving (5.8%), and intraneural excision (1.9%). Additional major surgical procedures involved the digestive tract in 82.7% of the cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of the cases. Self-catheterization was required in 14 cases (27%) at 3 weeks after surgery and in 3 women (5.8%) 12 months later. One-year follow-up showed significant improvement in quality of life measured using the Short-Form 36 questionnaire and standardized gastrointestinal scores. De novo hypoesthesia, hyperesthesia, or allodynia were recorded in 9 women (17.2%). The cumulative pregnancy rate was 77.2%% after natural conception in 47%. Conclusion Laparoscopic management of deep endometriosis involving the sacral roots and sciatic nerve improves patients’ symptoms and overall quality of life. Although pain reduction may be rapid after surgery, other sensory or motor complaints, including bladder dysfunction, may be recorded over months or years.

OBJECTIVES The aim was to compare the feasibility of ultrasound-guided multiple nerve blocks (fascia iliaca compartment block+sacral plexus block+superior cluneal nerve block) with general anesthesia in geriatric hip fracture patients. METHODS Ninety-four patients were randomly divided into 2 groups: group N received ultrasound-guided multiple nerve blocks and group G received general anesthesia. Primary outcome measures included perioperative Pain Threshold Index (PTI) and Numerical Rating Scale. Secondary outcome measures comprised the following: (1) perioperative Delirium Index and Short Portable Mental Status Questionnaire; (2) perioperative Comfort Index; (3) perioperative opioid consumption (within 72 hours postoperatively); and (4) postoperative side effects (within 72 h postoperatively). RESULTS Eighty-seven patients completed the study. Baseline PTI was comparable between the groups. However, intraoperative PTI was significantly lower in group N than in group G. Preoperative and postoperative Comfort Index scores were comparable between the groups. Moderate delirium (24 to 72 h postoperatively) was significantly higher than the baseline in group G. Early moderate delirium (24 h postoperatively) was significantly higher in group G than in group N. Severe delirium was comparable between the groups and within each group. High intraoperative PTI was associated with high opioid consumption. The intravenous sufentanil dose in group G was twice of that in group N. Incidence of nausea and vomiting was similar between the groups. DISCUSSION Ultrasound-guided multiple nerve blockade may be an alternative to the common anesthetic procedures used for geriatric hip fracture patients. It provided satisfactory intraoperative pain management and reduced early postoperative cognitive disorders.

Background: To compare the Adequacy of combined lumbosacral plexus block over subarachnoid block and epidural in terms of motor blockade and sensory blockade, surgeon and patient satisfaction and time for first rescue analgesia for unilateral elective hip surgeries. Materials and methods:A single centred randomized, single blinded study, conducted between May2017 to October 2018, on 60 patients undergoing elective unilateral hip surgeries with 20 patients in each group (group I -combined lumbar and sacral plexus block, Group II - Epidural & Group III- Subarachnoid block). Patients belonging to American society of anaesthesiologists, physical status 1 & 2, aged between 18 – 60 years were enrolled for the study and distributed randomly into one of the three groups. Adequacy of block in terms of motor and sensory blockade, patient and surgeon satisfaction and time for first analgesia were noted.

The local anesthetic injectate spread with fascial plane blocks and corresponding clinical outcomes may vary depending on the site of injection. We developed and evaluated a supra-iliac approach to the anterior quadratus lumborum (QL) block and hypothesized that this single injection might successfully block the lumbar and sacral plexus in cadavers and provide analgesia for patients undergoing hip surgery. Ultrasound-guided bilateral supra-iliac anterior QL blocks were performed with 30 mL of India ink dye in six fresh adult cadavers. Cadavers were subsequently dissected to determine distribution of the dye. In five patients undergoing hip surgery, a unilateral supra-iliac anterior QL block with 25 mL ropivacaine 0.5% followed by a continuous catheter infusion was performed. Patients were clinically assessed daily for block efficacy. The cadaveric injections showed consistent dye involvement of the majority of the branches of the lumbar plexus, including the femoral nerve, lateral femoral cutaneous nerve, ilioinguinal nerve, and iliohypogastric nerve. The majority of cadaveric specimens (83%) also exhibited thoracic paravertebral spread of dye to the T10 level. No specimens showed L5 or sacral nerve root staining or caudal spread below L5. All patients had effective analgesia for total hip surgery and a T11–L3 sensory level following the initial bolus of local anesthetic as well as during the period of continuous catheter infusion. This cadaveric study and case series show that a supra-iliac approach to the anterior QL block involved T10-–L3 nerve territories and dermatomal coverage with no sacral plexus spread. This technique may have clinical utility for analgesia in hip surgery.

Introduction: Anesthesia management for high-risk elderly patients with hip fracture is challenging, it is significant to choose a more minimally invasive anesthesia technique for them than using conventional methods, like general anesthesia and neuraxial anesthesia. Patients concerns: Herein the patient suffered from the right intertrochanteric fracture, combined with heart failure, renal failure at the stage of uremia and pneumonia in her upper left lung Diagnosis: Because of right intertrochanteric fracture, internal fixation with proximal femoral intramedullary nail was scheduled for this patient Interventions: Ultrasound-guided “hourglass-pattern” fascia iliac block combined with sacral plexus and gluteal epithelial nerve block were performed to a high-risk elderly patient Outcomes: The surgery in our report was successfully completed with our effective anesthesia technique and no perioperative complication occurred Conclusion: Ultrasound-guided “hourglass-pattern” fascia iliac block combined with gluteal epithelial nerve block and sacral plexus block not only satisfied the anesthesia and provided effective postoperative analgesia of hip operation, but also has minimal invasion to high-risk elderly patients, and contributed to enhancing recovery after surgery

AIMS To analyze, in female rats, the anatomical and histological features of the urethra and its relationship with the vagina and clitoris, and its innervation. METHODS Seventeen adult female Wistar rats were used. Gross anatomy and acetylcholinesterase (AchE) histochemistry were performed to describe the urethral features, adjacent structures, and innervation. The histomorphometric characteristics of the urethra were determined in transversal, longitudinal, or coronal sections stained with Masson's Trichrome. RESULTS The female rat urethra is not a homogeneous tubular organ. The pre-pelvic and pelvic regions are firmly attached to the vagina with belt-like striated fibers forming a urethra-vaginal complex. The bulbar regions have curved segments and a narrow lumen. The clitoral region is characterized by a urethra-clitoral complex surrounded by a vascular plexus. The lumen area and thickness of the urethral layers significantly varied between regions (P

We report a very rare case of a unilaterally absent piriformis muscle in a 60year old woman. Accompanying variations comprised a common gluteal artery (instead of two distinct superior and inferior gluteal arteries), and an absent gemellus inferior muscle. The contralateral left side showed a normally developed piriformis muscle. In hominoids, the piriformis is constant, but is regularly missing in several other vertebrates. The piriformis muscle is an anatomical landmark for ultrasound investigations and ultrasound-guided interventions in the deep gluteal region such as a superior gluteal nerve block or even a sacral plexus block, also for any surgical approach such as total hip arthroplasty. A missing piriformis muscle therefore affects the orientation in the deep gluteal region and therefore the identification of the targeted structures.

The authors describe in a clinical case series (n = 7) of older (age 78-95 years) high-risk patients the successful surgical treatment of proximal femoral fractures in a peripheral regional anesthesia technique. After positioning on the non-fractured side, a double injection technique (dual guidance concept: sonography plus nerve stimulation) was chosen. The injections were performed parasacrally (blockade of the sacral plexus under the piriformis muscle) and lumbar-paravertebrally (psoas compartment block and transmuscular quadratus lumborum block). Per block 15 ml ropivacaine 0.5% or 20 ml ropivacaine 0.375% was administered. The total dose of 225 mg ropivacaine was never exceeded. In 5 out of 7 cases a supplemental medication with 2 times 5 μg sufentanil (n = 2) and/or 1-1.5 mg/kg body weight and h propofol (n = 4) was administered with spontaneous breathing. In addition to potential benefits, the authors also discuss limitations of the procedure, for example by the use of oral anticoagulants.

Study Objective To evaluate the clinical presentation and surgical outcome in patients with deep lateral pelvic endometriosis (dLPE). Design A retrospective multicentric study (Canadian Task Force classification II-2). Setting University tertiary referral centers. Patients One hundred forty-eight women with deep infiltrating endometriosis (DIE). Interventions Laparoscopic excision of DIE. Disease distribution was classified as follows: central pelvic endometriosis (CPE) when DIE involved 1 of the following anatomic sites: cervix, vagina, uterosacral ligaments, rectum, bladder, or pelvic peritoneum; superficial lateral pelvic endometriosis when parametria, ureters, or hypogastric plexus were involved; and dLPE in the presence of sacral plexus and/or sciatic nerve infiltration. Measurements and Main Results All patients showed CPE. LPE was detected in 116 cases (78.4%); among these, we observed dLPE in 41 patients (35.3%). dLPE occurred in 40% of women with CPE and in 72.7% of patients with hypogastric plexus involvement. Thirty women with dLPE (73.2%) received gastrointestinal or urologic resection in addition to gynecologic procedures compared with 40 patients (57.1%) without dLPE (p = .001). No differences were observed in terms of perioperative complications according to the presence of dLPE. According to univariate/multivariate analysis, chronic pelvic pain was the only predictor of dLPE (odds ratio = 3.041, p = .003). The median preoperative visual analog scale for dysmenorrhea (median = 8, range, 0–10) and dyspareunia (median = 5; range, 0–10) dropped to 0 after surgery. The median follow-up was 36 months (range, 6–66 months) with a recurrence rate of 8.8%. Conclusions dLPE is not a rare event in women with DIE. Complete laparoscopic removal of endometriosis seems to ensure benefit in terms of recurrence rate without increased surgical morbidities.

Background In male rats, the bulbourethral glands (Bu-Gs) are the unique accessory sexual glands surrounded by striated musculature. However, until now the role of this musculature was unknown. Objectives (i) To characterize the Bu-Gs striated muscular layer in male rats and determine its innervation and response to genital stimulation. (ii) To reveal the role of the Bu-Gs striated musculature in the release of glandular secretion. (iii) To elucidate the effect of bilateral ablation of the Bu-Gs on copulatory behavior and seminal fluid characteristics. Materials and methods Adult Wistar male rats were allocated in three experiments: in Experiment 1, the Bu-Gs striated musculature, innervation and reflex activity were determined by gross anatomy and histological and electrophysiological techniques; electromyographic activity of the Bu-Gs striated musculature was evoked with genital stimulation. In Experiment 2, Bu-Gs were analyzed after copulatory behavior of intact or animals with unilateral transected motor branch of the sacral plexus (MBSP). In Experiment 3, copulatory behavior and spermatobioscopy of males with bilateral ablation of the Bu-Gs or sham surgery were analyzed. Results The Bu-Gs striated fibers discharged in response to mechanostimulation of the prepuce, glans, and penile-urethra. Innervation of the Bu-Gs striated musculature originated from the MBSP; this nerve also innervates striated penile muscles. Unilateral transection of the MBSP significantly decreased the secretion from the ipsilateral Bu-G to the nerve transection. Bilateral ablation of Bu-Gs did not affect seminal plug formation but decreased semen viscosity. Discussion and conclusion The Bu-Gs striated musculature contributes to expel glandular secretion during sexual intercourse. The somatic control of Bu-Gs secretion is additional to the reported autonomic innervation supplied by the cavernosus nerve, which may underlie the synthesis of secretion as well as contraction of Bu-Gs smooth muscle.

We report the use of a sacral plexus catheter for continuous local anaesthetic infusion in a patient with a unilateral sacral ala fracture following a fall from a horse. Although sacral plexus blockade has been well described for lower limb surgery, an ultrasound‐guided continuous catheter technique for conservatively managed fractures has not been described. Despite appropriate oral analgesia, the patient reported severe pain, particularly in the right gluteal region, which meant she was unable to sit upright or take deep breaths. A sacral plexus catheter was inserted with ultrasound guidance and an initial bolus of 30 ml levobupivicaine 0.25% was delivered followed by infusion of 8 ml.h(−1) levobupivicaine 0.125%. Daily follow‐up and assessment were provided by the acute pain team. We judged the procedure to be a success as measured by an improvement in mobilisation, deep breathing, cough and patient satisfaction.

Background Robotic-assisted techniques have been implemented in the surgical treatment of tumors in the pelvis, abdomen, and thorax. In pelvic tumors, robotic-assisted techniques evade the need for sizable surgical exposure, but make stimulation of the nerves of the sacral plexus very difficult. Objective To describe how laparoscopic robotic-assisted surgery can couple with tools such as the nerve stimulator to aid in the resection of presacral masses emanating from the neural elements and potentially improve neurological outcome by preventing inadvertent injury to involved nerves. Methods A patient with a large presacral ganglioneuroma underwent resection using the DaVinci system (Intuitive Surgical, Sunnyvale, California) for robotic assistance. A nerve stimulator was coupled to the bipolar cautery instrument of the DaVinci robot to define the presence of functional nerves in the surroundings of the tumor. Results By coupling a nerve stimulator to the bipolar cautery instrument of the DaVinci robot (Intuitive Surgical), it was possible to identify important neural structures in close proximity to the tumor. After identifying functional nerves, the surgeon was able to preserve them and preserve neurological function avoiding motor dysfunction. Conclusion The use of a nerve stimulator coupled to the bipolar cautery instrument of the DaVinci robot (Intuitive Surgical) during laparoscopic, robotic-assisted surgery for resection of presacral masses is safe and feasible. In addition to the preoperative evaluation, intraoperative monitoring and stimulation of nerves in close proximity to the tumor and also exiting through neural foramina involved by the tumor allowed the surgeon to understand the anatomy and preserve neurological function while obtaining optimal surgical resection.

Objective To assess the efficacy of psoas compartment and sacral plexus block for pelvic limb amputation in dogs. Study design Prospective clinical study. Animals A total of 16 dogs aged 8 ± 3 years and weighing 35 ± 14 kg (mean ± standard deviation). Methods Dogs were administered morphine (0.5 mg kg−1) and atropine (0.02 mg kg−1); anesthesia was induced with propofol and maintained with isoflurane. Regional blocks were performed before surgery in eight dogs with bupivacaine (2.2 mg kg−1) and eight dogs were administered an equivalent volume of saline. The lumbar plexus within the psoas compartment was identified using electrolocation lateral to the lumbar vertebrae at the fourth–fifth, fifth–sixth and sixth–seventh vertebral interspaces. The sacral plexus, ventrolateral to the sacrum, was identified using electrolocation. Anesthesia was monitored using heart rate (HR), invasive blood pressure, electrocardiography, expired gases, respiratory frequency and esophageal temperature by an investigator unaware of the group allocation. Pelvic limb amputation by coxofemoral disarticulation was performed. Dogs that responded to surgical stimulation (>10% increase in HR or arterial pressure) were administered fentanyl (2 μg kg−1) intravenously for rescue analgesia. Postoperative pain was assessed at extubation; 30, 60 and 120 minutes; and the morning after surgery using a visual analog scale (VAS). Results The number of intraoperative fentanyl doses was fewer in the bupivacaine group (2.7 ± 1.1 versus 6.0 ± 2.2; p Conclusions and clinical relevance Psoas compartment (lumbar plexus) and sacral plexus block provided analgesia during pelvic limb amputation in dogs.