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BACKGROUND Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

The authors present the case of a 48-year-old man admitted for acute onset of paraplegia in a patient suffering from backaches for 1 week. The rapidly progressive motor disturbances had been evolving for approximately 12 hours. The entire spinal MRI showed an epidural mass at T4-T6 associated with extensive lesions of spondylodiscitis and a T7-T8 vertebral body loss of height. A large six-level laminectomy was performed. A tumoral etiology couldn’t be entirely excluded intraoperatively so that no fusion has been done at that time. The pathological exam revealed acute inflammatory lesions with no argument in favor of a tumoral process. Bacteriological exam of the pathological specimen and stools cultures were positive for Salmonella brandenburg. An episode of gastroenteritis after the ingestion of a pizza has been evoked. The antibiotic medication was prescribed for 12 weeks. Postoperative evolution was favorable with a possible march between bars 6 weeks after. The authors emphasize the pseudo-tumoral presentation in an immunocompetent patient, the lack of complications and the post-ingestion mechanism.

Aim To describe a new minimal invasive approach of the gluteal region which will permit to perform neurolysis of the pudendal and cluneal nerves in case of perineal neuralgia due to an entrapment of these nerve trunks. Method Ten transgluteal approaches were performed on five cadavers. Relevant anatomic structures were dissected and further described. Neurolysis of the pudendal nerve or cluneal nerves were performed. Landmarks for secure intraoperative navigation were indicated. Results The first operative trocar for the camera was inserted with regards to the iliac crest in the deep gluteal space. With the aid of pneumodissection, the infragluteal plane was dissected. The piriformis muscle was identified as well as the sciatic and the posterior femoral cutaneous nerve. Consequently, the sciatic tuberosity was visualized together with the cluneal nerves. Hereafter, the second trocar was introduced caudal to the first one and placed on an horizontal line passing at the level of the coccyx, allowing access to the ischial spine and the visualization of the pudendal nerve and vessels. A third 5 mm trocar was then inserted medial from the first one, permitting to dissect and transsect the sacrospinous ligament. The pudendal nerve was subsequently transposed and followed on its course in the pudendal channel. Conclusions A reliable exploration of the gluteal region including identification of the sciatic, pudendal, and posterior femoral cutaneous nerves is feasible using a minimal invasive transgluteal procedure. Consequently, the transposition of the pudendal nerve and the liberation of the cluneal nerves can be performed.

BACKGROUND The ganglion impar is the first pelvic ganglion of the efferent sympathetic trunk that relays pelvic and perineal nociceptive messages and therefore constitutes a therapeutic target. OBJECTIVE The objective of this single-center study was to evaluate the effectiveness of 3 repeated ganglion impar blocks in patients with chronic pelvic and perineal pain on intention-to-treat. STUDY DESIGN Retrospective single-center study. SETTING We reviewed the medical records of 83 patients with chronic refractory pelvic and perineal pain. On intention-to-treat analysis, 62 (74.7%) of the patients received 3 ganglion impar blocks. METHODS Ganglion impar block was performed with 0.75% ropivacaine via a lateral approach over the Co1-Co2 coccygeal joint with computed tomography (CT) guidance. The effectiveness of ganglion impar blocks was evaluated by visual analogue scale (VAS) before and 30 minutes after the blocks. Evaluation at least one month after the block was also performed by Patient Global Impression of Change (PGI-C). RESULTS A total of 220 blocks were performed, 193 (87.7%) of which were considered to be positive with immediate but transient improvement of pain by more than 50% and complete but transient pain relief after the procedure in 119 (54.1%) procedures. The variation of the VAS score before and after each block was statistically significant (P < 0.001). Similarly, the VAS score before repeated blocks was significantly improved with decreased pain intensity over time (P = 0.001). Analysis of the PGI-C one month after the block demonstrated improvement in 41% of cases in the overall population and in 43.6% of cases in the subgroup of 62 patients treated by 3 blocks. LIMITATIONS Retrospective study, short term follow-up. CONCLUSIONS Repeated ganglion impar blocks allowed short-term reduction of pain intensity with a moderate intermediate-term effect. Ganglion impar appears to be a useful therapeutic target to block the nociceptive message by acting on sensitization phenomena.Key words: Pudendal neuralgia, impar block, pain, perineal, coccygodynia.

The apparent failure of pudendal nerve surgery in some patients has led us to suggest the possibility of entrapment of other adjacent nerve structures, leading to the concept of inferior cluneal neuralgia. Via its numerous collateral branches, the posterior femoral cutaneous nerve innervates a very extensive territory including the posterior surface of the thigh, the infragluteal fold, the skin over the ischial tuberosity, but also the lateral anal region, scrotum or labium majus via its perineal branch. We described the pathophysiological features of cluneal neuralgia, the surgical technique and our preliminary results. We performed a transmuscular approach leading to the fat of the deep gluteal region. Exploration was continued cranially underneath the piriformis, looking for potential entrapments affecting the posterior femoral cutaneous nerve and the sciatic nerve. Nerve decompression on the lateral surface of the ischial tuberosity was then performed. A constant anatomical finding must be highlighted: the presence of a lateral fibrous expansion from the ischium passing behind the nerves and vessels, especially the posterior femoral cutaneous nerve and its perineal branches. In our patients, release of this expansion allowed decompression of the nerve trapped by this expansion. Cluneal neuralgia constitutes a distinct entity of perineal pain, which must be identified and distinguished from pudendal neuralgia. Surgery should be performed via a transgluteal approach. A lateral ischial obstacle must be investigated, in the form of a constant fibrous expansion, which, like a retinaculum, can cause nerve entrapment.

AIM The surgical assumption of responsibility of the pancreatic pain requires either a truncular coelioscopic or radicular neurectomy of greater splanchnic nerves (gsn). The goal of our work is to describe the way and relations of the right gsn which are variable and rarely described. This constitutes an undeniable peroperational hemorrhagic risk during splanchnicectomy. MATERIAL AND METHODS After a double side thoracotomy and a bilateral sterno-clavicular desarticulation on 15 adult cadaveric subjects preserved by method of Winckler we removed the sterno-costal drill plate as well as the ventral rib arch and proceeded to a mediastinal evisceration of the thorax. Then we respected only the thoracic aorta and the oesophagus, the azygos venous system, the thoracic duct and the thoracic sympathetic chain. In some of the subjects, the azygos vein was injected (after catheterization of its stick) using gelatine coloured with blue paint. We studied the way and vascular relations of the right gsn. We measured the transverse distances between the origin of the gsn on one hand and the longitudinal axes of the azygos vein and the thoracic duct on the other hand. RESULTS The relations of the right gsn trunk during its way related to the azygos vein in particular its constitutive origin and its affluents: ascending lumbar vein and twelfth intercostal vein. Sometimes the thoracic duct even a lymphatic node was near the gsn in the posterior infra-mediastinal space. A classification of the way and vascular relations of the right gsn in the thorax identified 3 anatomical types. The average distances separating the right gsn on one hand from the azygos vein and the thoracic duct on the other hand were respectively 5.7 mm and 11.2 mm. CONCLUSION The vascular relations of the right gsn are very variable from one subject to another but primarily venous, sometimes lymphatic. They concerned the great thoracic vessels whose respect is essential in particular at the time of mini-invasive access procedure for a cœlioscopic splanchnicectomy.

Resumen Los cambios que se estan produciendo en los paises occidentales obligan a los sistemas sanitarios a adaptarse a las nuevas necesidades y expectativas de la poblacion. En Cataluna se esta produciendo una profunda transformacion del modelo asistencial, con el fin de poder dar una respuesta adecuada a esta nueva situacion y a la vez garantizar la sostenibilidad del sistema en un contexto de crisis economica. Esta transformacion se basa en convertir el actual modelo asistencial centrado en la enfermedad y fraccionado por niveles en otro centrado en la persona, integrado y de base territorial, que promueva el trabajo compartido en red de los diferentes profesionales, dispositivos y niveles asistenciales, estableciendo objetivos comunes explicitados en acuerdos y pactos territoriales. Los cambios que ha llevado a cabo el Servei Catala de la Salut (CatSalut) pasan principalmente por incrementar la capacidad de resolucion de la atencion primaria, reducir la variabilidad de la practica clinica, evolucionar hacia hospitales mas quirurgicos, potenciar las alternativas a la hospitalizacion convencional, desarrollar modalidades de atencion no presencial, concentrar y sectorizar territorialmente la atencion de alta complejidad y disenar codigos sanitarios especificos, como respuesta a situaciones de emergencia. La finalidad de estas actuaciones es mejorar la efectividad, la calidad, la seguridad y la eficiencia del sistema asegurando la equidad de acceso de la poblacion y el equilibrio territorial. Entre los instrumentos que deben facilitar y promover estos cambios cabe destacar la historia clinica compartida, el nuevo modelo de contratacion y pago por resultados, los pactos territoriales, las alianzas entre centros, el aprovechamiento de las potencialidades de las tecnologias de la informacion y la comunicacion, y la evaluacion de resultados.

Background: Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. Objectives: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. Study Design: Observational study. Setting: University hospital. Methods: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. Results: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock’s canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients. Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. Limitations: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. Conclusions: This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve. Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach

The changes taking place in western countries require health systems to adapt to the public's evolving needs and expectations. The healthcare model in Catalonia is undergoing significant transformation in order to provide an adequate response to this new situation while ensuring the system's sustainability in the current climate of economic crisis. This transformation is based on converting the current disease-centred model which is fragmented into different levels, to a more patient-centred integrated and territorial care model that promotes the use of a shared network of the different specialities, the professionals, resources and levels of care, entering into territorial agreements and pacts which stipulate joint goals or objectives. The changes the Catalan Health Service (CatSalut) has undergone are principally focused on increasing resolution capacity of the primary level of care, eliminating differences in clinical practice, evolving towards more surgery-centred hospitals, promoting alternatives to conventional hospitalization, developing remote care models, concentrating and organizing highly complex care into different sectors at a territorial level and designing specific health codes in response to health emergencies. The purpose of these initiatives is to improve the effectiveness, quality, safety and efficiency of the system, ensuring equal access for the public to these services and ensuring a territorial balance. These changes should be facilitated and promoted using several different approaches, including implementing shared access to clinical history case files, the new model of results-based contracting and payment, territorial agreements, alliances between centres, harnessing the potential of information and communications technology and evaluation of results.

The management of chronic pelvic and perineal pain has been improved by a better understanding of the mechanisms of this pain and an optimized integrated multidisciplinary approach to the patient. The concept of organic lesions responsible for a persistent nociceptive factor has gradually been replaced by that of dysregulation of nociceptive messages derived from the pelvis and perineum. In this setting, painful diseases identified by organ specialists are usually also involved and share several common denominators (triggering factors, predisposing clinical context). These diseases include painful bladder syndrome, irritable bowel syndrome, vulvodynia, and chronic pelvic pain syndrome. The painful symptoms vary from one individual to another and according to his or her capacity to activate pain inhibition/control processes. Although the patient often attributes chronic pain to a particular organ (with the corollary that pain will persist until the organ has been treated), this pain is generally no longer derived from the organ but is expressed via this organ. Several types of clinical presentation of complex pelvic pain have therefore been pragmatically identified to facilitate the management of treatment failures resulting from a purely organ-based approach, which can also reinforce the patient's impression of incurability. These subtypes correspond to neuropathic pain, central sensitization (fibromyalgia), complex regional pain syndrome, and emotional components similar to those observed in post-traumatic stress disorder. These various components are also often associated and self-perpetuating. Consequently, when pelvic pain cannot be explained by an organ disease, this model, using each of these four components associated with their specific mechanisms, can be used to propose personalized treatment options and also to identify patients at high risk of postoperative pelvic pain (multi-operated patients, central sensitization, post-traumatic stress disorder, etc.), which constitutes a major challenge for prevention of these types of pain that have major implications for patients and society.

Anterior screw fixation is a well-recognized technique that is used to stabilize Type IIB fractures of the odontoid process in the elderly. However, advanced age and osteoporosis are 2 risk factors for pseudarthrosis. Kyphoplasty has been described in the treatment of lytic lesions in C-2. The authors decided to combine these 2 techniques in the treatment of unstable fractures of the odontoid. Two approximately 90-year-old patients were treated for this type of fracture. Instability was demonstrated on dynamic radiography in one patient, and the fracture was seen on static radiography in the other. Clinical parameters, pain, range of motion, 36-Item Short Form Health Survey (SF-36) score (for the first patient), and radiological examinations (CT scans and dynamic radiographs) were studied both before and after surgery. After inflating the balloon both above and below the fracture line, the authors applied a high-viscosity polymethylmethacrylate cement. Some minor leakage of cement was noted in both cases but proved to be harmless. The screws were correctly positioned. The clinical result was excellent, both in terms of pain relief and in the fact that there was no reduction in the SF-36 score. The range of motion remained the same. A follow-up CT scan obtained 1 year later in one of the patients showed no evidence of change in the materials used, and the dynamic radiographs showed no instability. This combination of kyphoplasty and anterior screw fixation of the odontoid seems to be an interesting technique in osteoporotic Type IIB fractures of the odontoid process in the elderly, with good results both clinically and radiologically.

It has been this author's observation that over the last decade, there has been an obvious decrease in the number of revival meetings being conducted by Southern Baptist Churches (SBC) in Texas. Therefore, this topic was chosen because there seems to be a correlation between the decline of the membership and baptisms of Southern Baptist churches and the number of revivals that are being conducted. The potential value of this topic is that once the facts are discovered, this author hopes to encourage pastors and churches to bring back revivals to reach people with the gospel. This subject will be approached by taking a survey among Texas Southern Baptist churches that will show the correlation mentioned above. Using books that show the importance on revivals, this author will present steps that will benefit those wanting to revive revivals.