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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.

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.

Introduction: Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value. The goal of our study was to assess the risk of postoperative complications related to live surgery broadcast from the surgeon's routine theater, in patients managed for deep endometriosis infiltrating the digestive tract. Material and methods: We report a retrospective comparative study, enrolling women managed for colorectal endometriosis by a gynecologic surgeon, from September 2013 to March 2020 in two referral centers. We compared the rate of postoperative bowel fistula in women managed during live surgery in the routine operating theater, with that observed in women for whom surgery was not broadcast. Results: Among 813 women, 33 (4.1% of cases) underwent surgical procedures transmitted live to various conference rooms located outside the hospital and were compared with 780 patients who underwent non-broadcast surgery. Women's age, body mass index, past surgical and obstetrical history, and major preoperative complaints were comparable. Cases presented with impaired constipation score, more frequent sciatic pain, and infiltration of the vagina, whereas overall revised American Fertility Society classification scores were more severe in controls. The rate of rectal nodules over 3 cm in size was comparable between the two groups (72.7% in cases vs. 72.1% in controls). Operative time was also comparable (153 ± 52 minutes vs. 148 ± 79 minutes). Cases were more frequently managed by disk excision of rectal nodules (63.7% vs. 30.3%), and more frequently involved the sacral plexus (18.2% vs. 7.3%). Postoperative complications were comparable between the two groups, in terms of bowel fistula (3% in the live surgery group vs. 4.1% in controls), pelvic abscess requiring secondary laparoscopy (3% vs. 4.9%), or bladder dysfunction requiring self-catheterization after discharge (6.1% vs. 5.3%). Conclusions: Performing laparoscopic management of colorectal endometriosis with live transmission of surgery from a surgeon's routine operating theater, is not related to a higher risk of major postoperative complications.

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.

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.

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.

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.

Localized hypertrophic neuropathy (LHN) are slowly growing nerve lesions causing progressive nerve deficit and weakness. We present the case of a 32-year old woman with long history of motor and sensory deficit complains along the sciatic nerve territory. The muscles involved were featured by delay in F waves at nerve conduction assessment. Magnetic resonance imaging (MRI) showed specific patterns, low intense on T1 and abnormally hyper intense on short tau inversion recovery (STIR) and T2, with no obvious enhancement, features compatible with either LHN or intraneural perineurioma (IP) of the sciatic nerve and/or the lumbosacral plexus. Focal thickening and hypertrophy of the sciatic nerve with preserved fascicular configuration and progressive enlargement of the right lumbosacral plexus could be noted. A nerve conduction assessment followed by an MRI eventually allowed to diagnose LHN, without performing a nerve biopsy. Although similar, LHN and IP are two distinct lesions which should be diagnosed and differentiated as soon as possible, to avoid potential complications due to delayed diagnosis and/or misdiagnosis.

Objective Surgical demonstration of combined sacral plexus neurolysis and laparoscopic laterally extended endopelvic resection for deep lateral infiltrating endometriosis. Design Video showing principles of neurolysis and laparoscopic laterally extended endopelvic resection applied to endometriotic surgery. Setting University tertiary referral center. Deep infiltrating endometriosis is an underestimated disease with real medical and clinical issues, recently classified as central pelvic endometriosis and lateral pelvic endometriosis further divided into superficial and deep according to the structures’ involvement [1] . The surgical removal of endometriotic foci remains the standard treatment. A wide knowledge of neuroanatomy and high skills in minimally invasive surgery are required to manage this challenging surgical scenario [2] . Interventions New surgical approach for deep lateral infiltrating endometriosis based on the principles of lateral extended endopelvic resection and neuropelviologic surgery [ 3 , 4 ]. The patient was a 35-year-old woman, para 1, with neuropathic pain radiating to the left leg and a cyclic menstrual disorder. A laparoscopically assisted neuronavigation and subsequent neurolysis allowed the identification of the lateral nodule without damage to the autonomic pelvic innervation [1] . Then, a complete resection of the internal vascular compartment was required to obtain a radical endometriotic eradication. Shaving and bladder resection were also performed to complete removal of the endometriotic foci. Conclusion The association of neuroanatomic knowledge and surgical oncologic principles applied to minimally invasive surgery should be considered to ensure an adequate surgical radicality and clinical benefit in patients with deep infiltrating endometriosis.

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.

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.

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.

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

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.

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.

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.

Study Objective To demonstrate the robot-assisted laparoscopic decompression approach to treat aberrant vessels entrapping the sacral nerves causing motor deficit. Design Video presentation of two cases. Setting Tertiary unit specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 23-year-old virgin female patient presented with right lower extremity weakness, which had progressed into a limp over the past year and dysmenorrhea with a VAS (visual analog scale) score of 10. Gynecological examination revealed a 2 cm endometrioma on the right ovary. Under neurological examination hypoesthesia on right peroneal and right tibial nerve-dermatomes and chronic denervation of the muscles innervated by L5-S1 were observed. Case 2: A 46-year-old gravidity 3 parity 3 female patient presented with non-menstrual left sciatic pain, which caused difficulties while wearing socks and high heels and climbing up stairs. Magnetic resonance imaging (MRI) revealed dilated vessels on the left sacral nerve roots. Interventions Robot-assisted laparoscopic sacral nerve decompression Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. First patient's electromyography (EMG) result was normal at the 3rd month control. Motor deficit of both patients were eliminated and they both recovered fully. Conclusion Motor deficit or pain radiating (i.e. sciatica) to lower extremities are usually caused by spinal cord problems. However, these symptoms could arise by anatomic structures obstructing the nerves travelling to target organs or by nerve injuries. Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by abnormal vessels crossing over the plexus. Accessing to the sacral plexus between lateral iliac vessels and iliopsoas muscle is crucial and stable instruments are crucial during surgery. Robotic-assisted laparoscopy allows this stability and decrease the possibility of complications. The robotic technique offers, three-dimensional vision, improved maneuverability and enhanced ergonomics in the deepest parts of the pelvis.

OBJECTIVE The aim of this study was to report on the use of laparoscopic implantation of leads on the branches of the sacral plexus for neuromodulation in the treatment of chronic pelvic pain (CPP) in a multidisciplinary setting with the help of electrophysiological neuromonitoring. MATERIALS AND METHODS Between 2012 and 2019, six female patients complaining of chronic pain and bladder and bowel dysfunctions underwent laparoscopic exposure and nerve identification with the help of electrophysiological neuromonitoring. A lead was placed laparoscopically in direct contact with the affected nerve. Pain intensity (numerous ranking scale [NRS]), generic health status (EQ-5D-5L), Becks Depressions Inventory (BDI-V), Pain Catastrophizing Scale (PCS), and Client Satisfaction Questionnaire (CSQ-8) were assessed pre-/postoperatively as well as three and six months after surgery. Statistical analysis was performed using Mann-Whitney U and Wilcoxon rank-sum test. RESULTS The median age was 36.5 years. NRS improved from a median of 9.5 preoperatively to 3.0 (p

Background and aims Hip surgery is commonly seen in aged patients. Anesthesia management for them is challenging; the selection of anesthesia method will have influence on the prognosis and life quality of patients. Ultrasound-guided T12 paravertebral block combined with L1-4 nerve roots block and sacral plexus block introduced in this paper. We have conducted this anesthesia on 4 aged patients who had accepted the total hip arthroplasty, all operations were finished successfully. Methods Four aged patients were scheduled for total hip arthroplasty. All of them suffer from various kinds of systemic diseases, have a weak cardio-pulmonary function, and are subject to multiple complications and high risks during analgesia and operations. Ultrasound-guided T12 paravertebral block combined with L1-4 nerve roots block and sacral plexus block was successfully used for the surgery. Results All operations were finished successfully, no opioid drugs or other sedation and analgesia drugs were used during the operations, and the patients had no discomfort. Conclusions T12 paravertebral block combined with L1-4 nerve roots block and sacral plexus block can completely block the motion, feeling and sympathetic nerve of the hip joint, and provide a safe and effective anesthesia method for elderly patients who receive hip surgery.

Background and aims According to the National Institutes of Health, the elderly population comprised 8.5% of the entire population in 2016, mostly coming from Asia, and this is expected to double in 35 years. The majority of them undergo hip surgeries for osteoporotic fractures. There is the little in the literature on the anesthetic management of an extremely old age (>100 years) and these suggest that routine anesthetic care may be neurotoxic to a vulnerable brain. This paper presents the use of combined lumbar and sacral plexus block in a 110-year-old female – a rare case considering her age, with impaired pulmonary and renal function, and kypholordosis, who undergone an elective right hip surgery (dynamic hip screw). Methods An out-of-plane approach with dual guidance from ultrasound and nerve stimulator was used for lumbar and sacral plexus block. After infiltration of local anesthetic, complete motor and sensory block of the right thigh was achieved after 20 minutes. Results The anesthesia provided by the lumbar and sacral plexus block lasted for 4 hours with minimal pain in the postoperative period. The patient was discharged 2 days after surgery and was able to ambulate with a walker. Conclusions Combined lumbar and sacral plexus block can be used as a sole anesthetic technique in hip surgery. It is considered safe in elderly patients who cannot tolerate general and central neuraxial anesthesia.

Background and aims The author reports 3 patients in which computed tomography (CT) was used for epidural catheter placement in a patient with severe congenital scoliosis. Previously 3 attempts for spinal anaesthesia failed. Postoperative period after a sole general anaesthetic and opioids was associated with persistent pain, nausea and vomiting. Methods 3 patients with severe scoliosis scheduled for hip and knee surgeries had failed spinal anaesthesia during previous surgeries. Patients were not willing for a lumbar and sacral plexus block. After obtaining informed consent, CT guided lumbar epidural catheter placement was performed preoperatively. The patients had severe dextrorotatory thoracic scoliosis with a Cobb’s angle of more than 60 degrees and a compensatory laevorotatory lumbar curve of more than 40 degrees. In the axial scan, L3 vertebral area was identified as most easy to be approached through the defect in the intervertebral foraminal route. At a distance of 3 cm from the L2-3 spinous process, the needle was directed towards the convexity. The epidural space was identified with a loss of resistance at a depth of 6 cm and was secured at 10 cm at skin. After a test dose (3 ml of 2% adrenaline: lidocaine), surgery was performed under sequential epidural anaesthesia. Results The epidural provided adequate perioperative and postoperative pain relief for 48 hours in all 3 patients. Conclusions Anatomic deformity is an independent predictor of difficulty in performing neuraxial anaesthesia. CT guided neuraxial anaesthesia is an alternative in such difficult situations for providing good perioperative, opioid sparing analgesia.

Objective: To show the interest of tractography in pelvic surgery by a demonstrative case of neurofibroma resected by robotic assisted laparoscopy. Summary background data: Although diffusion tensor magnetic resonance imaging, along with tractography algorithms, is increasingly included in image guided neurosurgery methods, it is less frequently used for the peripheral nervous system such as the pelvic sacral plexus. We report one observation demonstrating the interest of such image data for pelvic surgery. Methods: A 12-years-old girl with neurofibromatosis presented with a growing left pelvic neurofibroma on repeated pelvic MRI with an increased SUV (2.83) on PET scan. A diffusion tensor pelvic MRI was performed before and after robotically assisted tumoral resection, and a tractography algorithm was applied on both images. Results: The pre-operative tractogram showed the nervous nature of the tumor in close contact with the left sacral plexus. Section of a nerve trunk encased in the neurofibroma was mandatory for the resection and well documented by the 3D enhanced vision provided by the robot. Post-operatively, the patient showed a slight paresthesia and dysesthesia of the left leg calf and of the plantar vault (left S2 territory), without any motor deficit. The post-operative tractogram showed a thinning of the left S2 sacral root and the disappearance of right aberrant nervous tracts. Conclusions: This clinical case validates the ability of pelvic tractography to deliver a proper imaging of the sacral nervous network and emphasizes the potential usefulness of this approach in pelvic surgery management, with perspectives of image-guided surgery. Keywords: NF1, Tractography, MRI, Robotic pelvic surgery

Rationale: For hip or knee arthroplasty, it is essential to develop a satisfied peripheral nerve block method that will benefit elderly patients or patients who are contraindicated to neuraxial anesthesia. Patients concerns: Patient in Case 1 suffered from the right intertrochanteric fracture, combined with chronic obstructive pulmonary disease; Patient in Case 2 suffered from hip osteoarthritis; combined with ankylosing spondylitis; Patient in Case 3 suffered from rheumatoid arthritis, combined with ischemic encephalopathy. Diagnosis: Case 1: Right intertrochanteric fracture, chronic obstructive pulmonary disease. Case 2: hip osteoarthritis. Case 3: rheumatoid arthritis. Interventions: Ultrasound-guided lumbar selective nerve root block (SNRB) plus T12 paravertebral and sacral plexus block were performed in 2 patients who received hip arthroplasty and 1 patient who received knee arthroplasty. Outcomes: All patients successfully received surgeries with this peripheral nerve block method and no postoperative complication was reported. Lessons: Ultrasound-guided lumbar SNRB plus T12 paravertebral and sacral plexus block not only satisfied the analgesia requirement of surgery, but also reduced the consumption of local anesthetic.

Background: Fecal incontinence is a common disorder in old age; however, it may not threaten life, but it can cause morbidity and many problems. Sacral nerve stimulation (SNS) is a minimally invasive surgical procedure performed by chronic electrical stimulation of the nerves in the sacral plexus through a lead implanted at the S3 foramen. This study aimed to evaluate the outcomes of SNS in Shiraz. Materials and Methods: Data from patients who underwent implantation of an SNS device from 2012 to 2018 were reviewed in Shiraz. Thirty patients who had incontinence were evaluated by a committee. Pre- and postoperative assessments of the severity of incontinence were performed using Wexner Incontinence Score. Statistical analysis was performed using paired t-test. Results: Twenty-seven patients proceeded to insertion in the temporary SNS, and of these, 16 were elected to have a permanent SNS. Finally, seven patients were satisfied with their treatment. There was a significant reduction in the pre- and post-SNS Wexner Incontinence Scores from a median of 15–10, respectively (P < 0.05). Conclusion: In our study, 16 patients underwent SNS protocol, and 43.7% of them showed a good response and recovered. It is recommended as a method for the treatment of fecal incontinence. Permanent SNS is effective, showing a significant improvement in fecal incontinence scores.

Background Aging causes progressive deterioration of all the organ systems. Physiological changes of aging and co-morbidities make regional anesthesia a preferred technique for this age group. Regional anesthesia with risk of hypotension and its consequences is fraught with dangers. Peripheral nerve blocks (PNBs) are much safer and give much superior post-op analgesia. The present study was undertaken to perform major lower limb orthopedic surgeries PNBs in geriatric settings. Methods A feasibility study was undertaken in patients above age of 60 years admitted for lower limb surgeries to undertake these surgeries under para-vertebral blocks for a period of one year from Mar 2011 to Feb 2012. Results The responses and results of 203 eligible patients averaging 69.5 years. Mean duration of surgical procedure was 174.6 min and surgical analgesia was 334.5 min. Mean time of analgesic supplementation postoperative 398.3 min. The incidence of adverse effects (hypotension) requiring intervention was 5 out of 203, failure rate 2 out of 203. Conclusion All major lower limb surgeries can be done under combined lumbar and sacral plexus block with additional supplementation for the skin at the line of incision especially in case the surgery involving hip with intercostal block at 11th ICS. The study strongly recommends it as a technique of choice in geriatric cases rather than reserving it for only moribund cases.

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

BACKGROUND Lower-limb function is severely impaired after sacral plexus nerve injury. Nerve transfer is a useful reconstructive technique for proximal nerve injuries. OBJECTIVE To investigate the clinical effectiveness and safety of transferring the ipsilateral obturator nerve to the branch of the tibial nerve innervating the medial head of the gastrocnemius muscle to recover knee and ankle flexion. METHODS From 2007 to 2011, 5 patients with sacral plexus nerve injury underwent ipsilateral obturator nerve transfer as part of a strategy for surgical reconstruction of their plexuses. The mean patient age was 31.4 years (range, 19-45 years), and the mean interval from injury to surgery was 5.8 months (range, 3-8 months). The anterior branch of the obturator nerve was coapted to the branch of the tibial nerve innervating the medial head of the gastrocnemius muscle by autogenous nerve grafting. RESULTS Patient follow-up ranged from 24 to 38 months. There were no complications related to the surgery. Three patients recovered to Medical Research Council grade 3 or better in the medial head of the gastrocnemius muscle. Thigh adduction function was not affected in any patient. CONCLUSION Knee and ankle flexion can be achieved by transferring the anterior branch of the obturator nerve to the branch of the tibial nerve innervating the medial head of the gastrocnemius muscle, which is useful for balance. This procedure can be used as a new method for treating sacral plexus nerve injury. ABBREVIATION MRC, Medical Research Council.

A 67-year-old man presented with a 2-month history of pain in his right buttock and lower limb. MRI depicted right L5/S1 lateral recess stenosis requiring surgical treatment; however, preoperative CT showed an approximately 7 cm long, thin, rod-shaped structure in the rectum, which was ultimately determined to be an accidentally ingested toothpick. It was removed surgically 6 days after diagnosis, because right leg pain worsened rapidly. The pain disappeared thereafter, and the symptoms have not recurred since. The pain might have been localised to the right buttock and posterior thigh in the early stages because the fine tip of the toothpick was positioned to the right of the anterior ramus of the S2 spinal nerve. Although sacral plexus disorder caused by a rectal foreign body is extremely rare, physicians should be mindful to avoid misdiagnosis.

In human anatomy, piriformis muscle and peripheral nerve variants may represent an unrecognized etiology. These variations in the gluteal region may cause entrapment of the sciatic nerve and induce to the piriformis syndrome. We present a case of accessory piriformis muscle accompanying to high divisions of sciatic nerve, unusual course of nerves and fusion of the piriformis muscle with gluteus medius in the left gluteal region of a 64-year-old male cadaver. The nerves which are originating from dorsal part of the sacral plexus, inferior gluteal nerve, common fibular part of the sciatic nerve and posterior femoral cutaneous nerve are located between the piriformis and accessory piriformis muscles make this case the most interesting of its kind. Awareness of these variations may prove to be useful for surgeons during the surgery of the gluteal region and the clinician when treating patients with buttock pain. Additionally, the possible role of aberrant anatomical variations of the related region in causing piriformis syndrome must be taken into consideration as one of the contributing factors.

Study Objective To report outcomes of the vascular entrapment of the sacral plexus treated by minimally invasive surgery. Design Retrospective cohort study. Setting Tertiary unit specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants A total of 23 patients suffering from chronic pelvic pain with the involvement of the lumbosacral plexus were included in this study. 9 out of 23 patients underwent robot-assisted laparoscopic surgery and conventional laparoscopic surgery with 3D technology were performed in 14 patients for treatment of the vascular entrapment of the lumbosacral plexus. Interventions Laparoscopic or robot-assisted laparoscopic excision of the abnormal vessels located on the lumbosacral plexus and decompression of the nerve roots. Measurements and Main Results The mean age of the patients was 35.13. All patients were suffering from chronic pelvic pain and the most common coexisting symptoms were dysmenorrhea, sciatica, vulvodynia and pudendal neuralgia. Motor deficit was seen only in two patients. Vascular entrapment was visualized on the left side in 16 patients and on the right side in 7 patients. Vascular entrapment of the lumbosacral plexus in different locations were first dissected then clipped (in 12 patients), coagulated and cut in all patients. Thrombosis of the external iliac artery occurred in one patient, postoperatively. In two patients pain persisted following operation and recurrence was observed in one patient. Conclusion Since lumbosacral plexus is located over the sacral bone, it can be entrapped easily by abnormal vessels crossing over the plexus. Radiating pain to lower limbs or genital area and also motor deficit of the lower limbs in patients with chronic pelvic pain were investigated in detail for the presence of vascular entrapment of the lumbosacral plexus. The minimally invasive surgery with three-dimensional vision provides improvement of the sensation of depth in the deepest parts of the pelvis and minimizes complications.

Study Objective To demonstrate decompression of sacral nerves from aberrant vessels and fibrous tissue located on the plexus. Design Video presentation of two cases. Setting Tertiary center specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 43-year-old gravidity 1 parity 1 female patient presented with dysmenorrhea, dyspareunia and pudendal pain with dysuria. Gynecological examination revealed deep infiltrative endometriosis with rectovaginal nodule and partial obliteration of pouch of Douglas. She had a history of laparoscopic endometriosis surgery with left oophorectomy and was treated with intravascular coil embolization for pelvic congestion syndrome. Case 2: A 41-year-old gravidity 1 parity 1 female patient presented with chronic pelvic pain and left sided sciatic pain with chronic dysesthesia in the dermatome of sciatic nerve without any motor deficit of lower extremity. Gynecological examination revealed deep infiltrative endometriosis and full obliteration of pouch of Douglas. She had a history of multiple laparoscopic and laparotomic operations for endometriosis. Interventions Robot-assisted laparoscopic sacral nerve decompression and dissection of cul-de-sac with rectal nodule shaving (case1) and laparoscopic sacral nerve decompression and dissection of cul-de-sac (case 2). Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. Both patients report significant pain reduction with visual analog scale score. Conclusion Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by an abnormal structure (abnormal vessels, fibrous tissue, tumor, etc.) located on the plexus. Deep infiltrative endometriosis may affect retroperitoneal tissue by causing fibrosis. An abnormal vessel, which is located on the sacral plexus may entrap the roots much easier with coexisting fibrosis. On six moths follow up the visual analog scale score of case 1 and 2 decreased from 10 to 4 and 10 to 3, respectively. Patients are still under surveillance.

Rationale: The anesthetic management of patients with severe pulmonary hypertension is different from that of normal, healthy patients, and regional nerve blocks are commonly used for them. Due to the individual variability of the course, distribution, and branching of the nerves below the inguinal ligament, the supra-inguinal fascia iliaca (SIFI) block has a wider and more stable blocking area. In combination with the sacral plexus block, they can satisfy the needs of surgical anesthesia below the hip. Patient concerns: A 46-year-old man with tuberculosis, chronic obstructive pulmonary disease, pulmonary heart disease, World Health Organization (WHO) class III pulmonary hypertension and right heart dysfunction, and American Society of Anesthesiologists physical status class III needed fixation of an intramedullary nail in the left lower extremity. Additionally, he had broken his left lower limb after a recent fall. Both general anesthesia and epidural anesthesia were not appropriate. Diagnoses: The patient had a clear history of tuberculosis, computerized tomography scan displayed destructive pneumonophthisis. Furthermore, he had chronic obstructive pulmonary disease and pulmonary heart disease. Interventions: An ultrasound-guided SIFI combined with a sacral plexus block was successfully performed for surgical anesthesia and avoided all hemodynamic fluctuations. Outcomes: We successfully performed an ultrasound-guided SIFI combined with a sacral plexus block for surgical anesthesia and avoided all hemodynamic fluctuations. Lessons: Ultrasound-guided suprainguinal fascia iliaca block combined with a sacral plexus block can be suitable for anesthesia for patients with severe circulatory compromise.

Idiopathic lumbosacral plexitis or lumbosacral radiculoplexus neuropathy is a disease characterized by nerve damage in lumbar and/or sacral plexus without trauma, mass effect or diabetic complications. A 47-year-old male patient with right groin pain and loss of right leg muscle strength is presented in this case report. Neuropathy was detected in the L4 nerve root by electromyography and magnetic resonance neurrographic imaging. The underlying cause was investigated; however, it is linked to the idiopathic outcome. Idiopathic lumbosacral neuropathy is a lumbosacral plexus disease in which no underlying pathology plays a role in causing severe pain and muscle weakness. Patients should be avoided urgently operation because of the sudden onset symptoms.

Lumbosacral plexus injuries usually occur in patients with severe, multiple traumas requiring intensive care, affecting gait function. The purpose of the present study was to identify the initial factors associated with gait outcome in lumbosacral plexus injuries caused by traumas. We retrospectively identified 664 patients with pelvic fractures caused by trauma between 2006 and 2017. The lumbosacral plexus injuries were electrodiagnostically confirmed in 30 patients (4.5%). Demographic, injury-related, fracture-related and electrodiagnostic factors were compared between patients with long-term unassisted gait outcomes to those with assisted gait outcomes, with an average of 27 months elapsing after the trauma. Eleven patients (36.7%) remained in the assisted gait group during the follow-up period. Complex pelvic trauma, rather than the severity of trauma to the entire body, was associated with a poor gait outcome. Among the various causes of injury, pedestrians struck by vehicles were associated with assisted gait outcomes. The number of anatomic locations involved in pelvic fractures, pelvic ring instability by Tile classification, and the proportion of unstable sacral fractures were higher in patients with assisted gait outcomes compared with those having unassisted gait outcomes. Weaknesses in the initial hip extensor, knee flexor, ankle dorsiflexor and ankle plantar flexor were observed significantly more often in patients with assisted gait outcomes. The Dumitru and Wilbourn’s scale of the anterior and posterior sacral plexus was significantly higher in the assisted gait group. Gait outcome after lumbosacral plexus injury is associated with the range and stability of the pelvic fracture and the severity of the anterior and posterior sacral plexus injury. Poor gait outcome was associated with the severity of the trauma to the pelvis rather than that to the entire body.

Objective: To evaluate the postoperative outcome after using combined lumbar and sacral plexus block (CLSB), as a sole anesthetic method in hip fracture (HF) surgery in highrisk geriatric patients. Materials and Methods: A single-center retrospective study was conducted, between 2010 and 2012, on 70 elderly HF patients with American Society of Anesthesiologists grading III-IV who underwent early surgical intervention with our CLSB protocol. Perioperative data, outcome, and complications were recorded. Results: Forty-eight patients (69%) had ongoing anticoagulant medication. Postoperatively, all patients were hemodynamically stable and awake. None of them required general anesthesia conversion. Minor anesthetic-related complications were found in nine patients. One patient (1%) died from sepsis due to pneumonia. Patients’ satisfactions were all rated as very good or excellent. Conclusion: CLSB is an interesting anesthetic option in HF surgery, especially in high surgical risk geriatric patients. This method offers an excellent clinical efficiency and high patients’ satisfaction without serious complications.

Endometriosis (EM) is an infrequent cause of peripheral neuropathy, most commonly sciatic. Perineural spread has recently been introduced as an alternate explanation for cases of lumbosacral or sciatic nerve EM. We performed a literature review to collect all reported cases of peripheral and central nervous system EM in search of anatomic patterns of involvement; potentially to support the perineural spread theory. If available, intraneural invasion and presence of peritoneal EM were recorded. The search revealed 83 articles describing 365 cases of somatic peripheral nervous EM and 13 cases of central nervous EM. The most frequently involved site was the sacral plexus (57%, n = 211), followed by the sciatic nerve (39%, n = 140). Other nerves were reported in significantly smaller numbers. Ninety seven percent (97%, n = 355) of peripheral nerve cases presented with pain, 20% (n = 72) reported weakness and 31% (n = 114), numbness. Thirty four percent (34%, n = 38) had solely intraneural EM of which 89% (n = 33) had no peritoneal EM (percentage based on available information). In the central nervous system, the conus medullaris and/or cauda equina constituted the majority of cases with 54% (n = 7). Apart from perineural spread, other discussed mechanisms include retrograde menstruation with peritoneal seeding, hematogenous and lymphogenous spread, stem cell implantation either hematogenously or via retrograde menstruation with subsequent EM differentiation, and coelomic or Mullerian duct metaplasia. We believe this literature review supports perineural spread as an alternate mechanism for EM of nerve, particularly the subgroup with intraneural EM and without peritoneal disease.

Se plantea el problema de la patogenia y tratamiento del dolor causado por el carcinoma uterino avanzado. En opinión de los autores es más aceptable la idea de que el dolor es causado por compromiso de los plexos lumbar y sacro en su trayecto intrapélvico y no por compromiso de vías simpáticas. Se señala la gran importancia de un estudio cuidadoso de la evolutividad de la neoplasia y de la presencia de complicaciones derivadas de ella, así como de una graduación de la severidad del dolor basada en el uso sistematizado de analgésicos, complementados en forma razonada por sedantes. Se señala las razones por las cuales somos opuestos al uso desordenado de opiáceos en pacientes que pueden ser aliviados definitivamente de su dolor por medios quirúrgicos. Se señala la importancia de evitar la adicción a narcóticos, fuente de problemas más graves que el dolor mismo. Se apoya a la sección de los haces espinotalámicos en la médula espinal (cordotomía ánterolateral), como el método quirúrgico de elección en el dolor por cáncer pélvico avanzado, cuando es incontrolable con dosis moderadas de analgésicos y el paciente presenta un buen "riesgo quirúrgico".

Endometriosis involving the sacral plexus is still poorly understood or neglected by many surgeons. Looking at that scenario, we have designed this educational video to explain and describe the symptoms suggestive of endometriotic involvement of the sacral plexus in addition to the technique for the laparoscopic treatment of this condition.Retrospective analysis of 13 consecutive cases of endometriotic entrapment of nerves of the lumbosacral plexus.Paired t test revealed a statistically significant (p 0.0000001) reduction in pain VAS score, from preoperative average 9.1 (±1.98) to postoperative 1.46 (±1.66). Twelve out of 13 patients (92.3%) experienced a reduction of 50% or more in VAS score and 6 (46.15%) became completely pain-free.The signs suggestive of intrapelvic nerve involvement include perineal pain or pain irradiating to the lower limbs, lower urinary tract symptoms, tenesmus or dyschezia associated with gluteal pain. Whenever deeply infiltrating lesions are present, the patient must be asked about those symptoms and specific MRI sequences for the sacral plexus must be taken, so that the equipment and team can be arranged and proper treatment performed.

Introduction The S2 alar-iliac (S2AI) screw is a modification of the traditional iliac fixation technique and has surgical and biomechanical benefits. However, there are significant regional neurovascular structures along the path of such screws. Therefore the current anatomic study was performed to better elucidate these relationships. Methods Using fluoroscopy, S2AI screws were placed in 2 adult cadavers through a standard posterior midline exposure. The screw insertion point was placed 10 mm lateral to a line bisecting the S1 and S2 foramina, adjacent to the sacroiliac joint. Using 30- to 40-degree lateral angulation from the midline and 20- to 30-degree caudal angulation, a pedicle probe was directed toward the anterior inferior iliac spine. The final trajectory was positioned to sit 1−2 cm superior to the greater sciatic foramen. Lastly, the screws and surrounding bone were drilled in order to visualize both lateral and medial neurovascular relationships. Results Removing the bone around the S2AI-screw illustrated the close relationship to the medial (internal) neurovascular structures including the obturator nerve, lumbosacral trunk, sacral plexus and, specifically, the S1 ventral ramus and iliac vein and artery. By removing the outer cortex of the ilium, the close relationship to the superior gluteal artery, vein, and nerve was observed. In addition, we were able to identify the proximity to the iliopsoas muscle and internal iliac vessels. Conclusions A comprehensive knowledge of the surrounding neurovascular anatomy relevant to S2AI screw placement can decrease patient morbidity and allow spine surgeons to better diagnose potential postoperative complications.

Introduction: There are situations in which block anesthesia would be the technique of choice, if the technique or techniques of blocking the lumbar and sacral plexus could be simplified, as they have been for brachial plexus. Aims and objectives: Aim of the study is to evaluate the effect of adding fentanyl and clonidine to Lignocaine with adrenaline in lumbar/sciatic block with regard to the following parameters: onset of complete motor and sensory block, duration of motor and sensory block, duration of analgesia, sedative effect of fentanyl and clonidine, hemodynamic changes, complications due to adjuvants and to compare both these adjuvants. Method study design: Patients were randomly allocated into 2 groups of 30 each. Groups: Groups L and C (lignocaine with adrenaline + clonidine)— 30 patients received 35 ml lignocaine with adrenaline + 10 ml distilled water diluted clonidine containing 100 µg + 5 ml distilled water, and groups L and F (lignocaine with adrenaline + fentanyl)—30 patients received 35 ml lignocaine with adrenaline + 10 ml distilled water diluted fentanyl containing 100 µg + 5 ml distilled water. Results: From present study, it can be concluded that Clonidine appears to be better adjuvant for prolongation of anesthesia and analgesia in lower limb surgeries under lumbar plexus/ sciatic block.