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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.

Myelin basic protein (MBP) contributes to peripheral and central nervous system myelin. Developmental myelinopathies exist on a clinical spectrum, but MBP is not included on leukodystrophy or CMT gene panels. This ring chromosome 18 case presents serial MRI and EMG/NCS, shedding light on the early clinical course of the disorder.

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.

Symptomatic vertebral hemangiomas during pregnancy are rare, as only 27 cases have been reported in the literature since 1948. However, symptomatic vertebral hemangiomas can be responsible for spinal cord compression, in which case they constitute a medical emergency, which raises management difficulties in the context of pregnancy. Pregnancy is a known factor responsible for deterioration of these vascular tumors. In this paper, the authors report 2 clinical cases of symptomatic vertebral hemangiomas during pregnancy, including 1 case of spontaneous fracture that has never been previously reported in the literature. The authors then present a brief review of the literature to discuss emergency management of this condition. The first case was a 28-year-old woman at 35 weeks of gestation, who presented with paraparesis. Spinal cord MRI demonstrated a vertebral hemangioma invading the body and posterior arch of T-3 with posterior epidural extension. Laminectomy and vertebroplasty were performed after cesarean section, allowing neurological recovery. The second case involved a 35-year-old woman who presented with spontaneous fracture of T-7 at 36 weeks of gestation, revealing a vertebral hemangioma with no neurological deficit, but it was responsible for pain and local instability. Treatment consisted of postpartum posterior interbody fusion. With a clinical and radiological follow-up of 2 years, no complications and no modification of the hemangiomas were observed. A review of the literature reveals discordant management of these rare cases, which is why the treatment course must be decided by a multidisciplinary team as a function of fetal gestational age and maternal neurological features.

Water erosion is the major cause of soil and water losses and the main factor of degradation of agricultural areas. The objective of this work was to quantify pluvial water erosion from an untilled soil with crop rows along the contour, in 2009 and 2010, on a Humic Dystrupept, with the following treatments: a) maize monoculture; b) soybean monoculture; c) common bean monoculture; d) intercropped maize and bean, exposed to four simulated rainfall tests of on hour at controlled intensity (64 mm h-1). The first test was applied 18 days after sowing and the others; 39, 75 and 120 days after the first test. The crop type influenced soil loss through water erosion in the simulated rainfall tests 3 and 4; soybean was most effective in erosion control in test 3, however, in test 4, maize was more effective. Water loss was influenced by the crop type in test 3 only, where maize and soybean were equally effective, with less runoff than from the other crops. The soil loss rate varied during the runoff sampling period in different ways, demonstrating a positive linear relationship between soil and water loss, in the different rainfall tests. A erosão hídrica é a principal causa das perdas de solo e água, assim como de degradação das áreas agrícolas. O objetivo deste trabalho foi quantificar a erosão hídrica pluvial em uma área sem preparo prévio do solo, cultivada em contorno, em 2009 e 2010, sobre um Cambissolo Húmico, com os seguintes tratamentos: milho solteiro, soja solteira, feijão solteiro e milho e feijão consorciados, submetidos a quatro testes de chuva simulada com intensidade constante de 64 mm h-1 e duração de 1 h. O primeiro teste foi aplicado 18 dias após a semeadura das culturas e, os demais, 39, 75 e 120 dias, após o primeiro. O tipo de cultura influenciou a erosão hídrica nos testes 3 e 4 de chuva simulada; a soja foi mais eficaz no teste 3, enquanto, no teste 4, o milho foi mais eficiente no controle da erosão. As perdas de água foram influenciadas pelo tipo de cultura apenas no teste 3, onde o milho e a soja demonstraram a mesma eficiência, com menores valores de enxurrada do que as demais culturas. A taxa de perda de solo variou de distintas formas ao longo do período de amostragem da enxurrada, demonstrando relação linear positiva entre as perdas de solo e as de água, nos vários testes de chuva simulada.

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

Rectal examination is difficult to carry out by students because of their lack of knowledge and fear. It is therefore necessary to search for methods in order to facilitate its practice. This work mainly focuses on the palpation of the posterior lateral area of the rectum. This work bases itself on the study of the average length of indexes and on the anatomical study of the dissection and prints of two pelvises. In the lithotomy position, we can identify three successive levels of exploration of the posterior and lateral area of the rectum. These three levels are defined by the extremity of the index, and the distal and proximal interphalangeal articulations placed successively on the tip of the coccyx. A 180° rotation of the hand enables at each level to identify the parietal structures that the pad of the index comes across, but excludes the palpation of genital organs and rectum. The first level corresponds to the higher part of the anal canal, the ischioanal fossa and the ischium. The second level corresponds to the levator ani muscle, the ischioanal fossa and the pudendal canal. The third level corresponds to the sacrospinous ligament, the ischiatic spine and the internal obturator muscle. In spite of the significant differences between the lengths of the indexes, the use of these landmarks will facilitate the identification of parietal anatomical structures. The internal organs’ palpation will depend on the patient’s position, his efforts in pushing, the length of the index, and the way the examiner presses on the perineum.

Objective Vascular damage in the cavernous sinus can cause ischemic injury to the cranial nerves. An appropriate anatomical knowledge of the blood supply to the cranial nerves can help to reduce the morbidity associated with cavernous sinus surgery. Material and methods Three formalin-fixed and six adult cadaveric fresh heads, with common carotid arteries injected, were used for anatomical dissection in this study. A fronto-temporal craniotomy was performed and the cavernous sinus was explored according to the Dolenc technique. With microsurgical dissection and photographic documentation, we demonstrate the anatomy of the superior orbital fissure artery in the antero-medial triangle. Results The 12 explored cavernous sinuses demonstrated the presence of two principal branches directly from the intracavernous internal carotid artery that supply the cranial nerves: the infero-lateral trunk and the meningohypophyseal trunk. The artery of the Superior Orbital Fissure (SOF), originated more often from the infero-lateral trunk, and vascularized the III, IV, VI, and VI, and ophtalmic division of the trigeminal nerve (TGN VI) at their entry in the fissure. Conclusion In this study we demonstrate that the superior orbital fissure artery is a branch from the infero-lateral trunk which runs immediately under the reticularis layer at the level of the anteromedial triangle in the lateral wall of the cavernous sinus. The blood supply to all cranial nerves in the SOF is at risk to injury when the lateral wall of the cavernous sinus is transgressed at the anteromedial triangle since the SOF-artery runs superficially at this level.

OBJECTIVES Surgery of pudendal nerve entrapment needs the section of both sacrospinal and sacrotuberal ligaments. We asked about the potential side effect of such a section especially on sacro-iliac joint stability. MATERIAL AND METHODS We performed a cadaveric anatomical and biomechanical study concerning six sacro-iliac joints. Joints were tested on a plateform, and results were analysed with a logiciel (Medai((R))), both especially developped for, before and after sacrospinal and sacrotuberal section. RESULTS The computered analysis of our results proved that sacro-iliac joint has a significant range of motion, specially in youngs. Results obtained confirmed that there is no statistical difference (p

Obturator neuralgia is a cause of pelvic and perineal pain that is rarely suggested, probably because it is poorly understood. We report the results of a pilot study of laparoscopic treatment for obturator neuralgia.Seven patients (8 nerves) with obturator neuralgia were treated at our department. The etiology was idiopathic in 3 cases and iatrogenic following inguinal hernia surgery in 3 and TVT(R) repair in 2. The diagnosis was based on allodynic pain of the anterior and internal surface of the thigh, which was associated with limping with a sidestepping gait. It was confirmed by an anesthetic block under computerized tomography monitoring using a posterior approach.Treatment consisted of transperitoneal laparoscopic neurolysis with dissection of the nerve and section of the scarring fibrosis or prosthetic mesh in contact with it. In idiopathic cases nerve release was performed by sectioning the internal obturator muscle and the obturator membrane, causing compression and making it possible to widen the obturator foramen. At a mean followup of 16 months the rate of an at least 50% improvement in pain was 87.5% (7 of 8 cases), including complete disappearance of pain in 50% (4 of 8).Minimally invasive treatment with laparoscopic truncular release of obturator neuralgia yielded encouraging and good results.

Aims: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis. Materials and Methods: A working party has validated a set of simple diagnostic criteria (Nantes criteria). Results: The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms. Conclusion: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis. Neurourol. Urodynam. 2007 Wiley-Liss, Inc.

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.

BACKGROUND: Most military helmets are designed to prevent penetration by small firearms using composite materials in their construction. However, the transient deformation of the composite helmet during a non penetrating impact may result in severe head injury. METHOD: Two experimental designs were undertaken to characterize the extend of injuries imparted by composite panels using in protective helmets. In the first series, 21 dry skulls were protected by polyethylene plates, with gaps between the protective plate and skull ranging from 12 to 15 mm. In another design, using 9 cadavers, heads were protected by aluminum, aramid, or polyethylene plates. Specimens were instrumented with pressure gauges to record the impact response. The ammunition used in these experiments was 9 mm caliber and had a velocity of 400 m/s. A macroscopic analysis of the specimens quantified fractures and injuries, which were then related to the measured pressures. RESULTS: Protective plates influenced both the levels of injury and the intracranial pressure. Injuries were accentuated as the plates was changed from aluminum to composite materials and ranged from skin laceration to extensive skull fractures and brain contusion. Fractures were associated with brain parenchymal pressures in excess of 560 kPa and cerebrospinal fluid pressure of 150 kPa. An air gap of a few millimeters between the plate and the head was sufficient to decrease these internal pressures by half, significantly reducing the level of injury. CONCLUSIONS: Ballistic helmets made of composite materials could be optimized to avoid extensive transient deformation and thus reduce the impact and blunt trauma to the head. However, this deformation cannot be completely removed, which is why the gap between the helmet and the head must be maintained at more than 12 mm.

Objective A series of ethmoidal tumors was resected by an entirely extracranial approach through a lateral rhinotomy incision, with partial maxillectomy and removal of the cribriform plate and dura mater from below. Methods Thirty-four consecutive patients (32 male, 2 female; mean age 64 years, range 45–78) with malignant tumors of the ethmoid sinus were operated by this technique between July 1998 and February 2002. All had complete tumor resection, including the cribriform plate and the dura mater. Excision was performed en bloc 23 times (68%). Although cerebral involvement was encountered in four cases (T4 IC), this technique was adequate for tumor resection, together with corticectomy when necessary. The method used for tumor resection and rebuilding of the anterior skull base is described in detail. Results There were no immediate postoperative deaths. One patient developed pneumococcal meningitis with cerebrospinal fluid leakage as a result of a technical error and required further surgery. Four patients presented a confusion syndrome that regressed during the hospital stay, 2 complained of transient diplopia, and 4 had hematoma of the abdominal wall. Mean follow-up of 10.4 months (1–41 months) is still too short to reach definitive conclusions about oncologic results. Conclusions This approach is particularly suitable for removal of tumors in contact with or invading the cribriform plate. Tumor resection is as extensive as with the traditional mixed approach, but does not require the frontal lobes to be drawn aside.

A study was made of 100 homogeneous CT scans of the petrous part of the temporal bone to determine whether or not the arcuate eminence (AE) is a good landmark for the superior semicircular canal (SSCC) in the suprapetrous approach to the internal acoustic meatus which is used in the extirpation of acoustic neuromas. Direct measurements were made on consecutive coronal sections, 1 mm thick. The AE was absent from the petrous surface in 15% of cases. It corresponded to the relief of the SSCC in 37% of cases; laterally, however, it was separated from the petrous cortex by bone whose thickness varied from 0.5 to 5 mm. Finally, in 48% of cases, the AE was not a good landmark for the canal although nonetheless it participated in the development of this bulge in 46% of cases, always lying towards the medial border of the pneumatized eminence. In addition, study of the coronal sections with MRI allowed us to confirm that the AE does not routinely correspond to the imprint of a temporal sulcus. The AE, whose presence on the petrous surface is due to the combined effects of the SSCC, the air cells of the petrous part of the temporal bone and the temporal sulci, is only a good guide to the SSCC in 37% of cases and should not be considered as a reliable surgical landmark.

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.

✓ The authors describe a case of arachnoiditis ossificans (AO) of the cauda equina. The lesion is a rare pathological entity usually confined to the thoracic and high lumbar regions that can cause progressive spinal cord and cauda equina compression, inducing severe neurological deterioration. The authors analyze the clinical symptoms, radiological features, histological data, and treatment options relating to this case and 13 others described in the literature; additionally, they consider the possible mechanisms responsible for ossification of the leptomeninges. Although clustered arachnoidal cells are usually implicated in its pathogenesis, an environment induced by arachnoiditis and disturbed cerebrospinal fluid flow appears to be a more important factor. A therapeutic strategy is proposed for AO for which no effective treatment currently exists.

✓ The authors describe an occipitocervical fixation procedure in which they use inverted occipital hooks inserted through a burr hole drilled in the squamous part of the occipital bone. Fifteen patients with unstable lesions of the occipitocervical junction underwent occipitocervical internal fixation. The mean follow-up period was 21 months (range 2–63 months). No implant failed, and postoperative immobilization was not required. The placement of a posterior occipitocervical graft (for which fusion is uncertain) can be avoided in certain conditions.

The authors report an exceptional and well-documented case of interruption of the retrohepatic segment of the inferior vena cava with an "azygos continuation", combined with absence of the portal vein. The only known combination of congenital anomalies of the inferior vena cava and the portal vein was that of an "azygos continuation" and a preduodenal portal vein. The double interruption, portal and inferior caval, may be associated with a disturbance of preferential flows induced by the left umbilical thrust. According to hemodynamic theory, the left umbilical flow is the determining factor in organogenesis of the portal vein and the retrohepatic segment of the inferior vena cava.

Injury to the mandibular marginal ramus of the facial n. constitutes a risk in cervicofacial surgery. The aims of this study were to define the origin of this nerve branch and its course and relations, especially with the lower border of the mandible and the facial vessels. Our observations revealed differences from the classical description of a single nerve branch traveling on the outer aspect of the body of the mandible above its lower border. We found several marginal branches, which become closely related to the facial pedicle, particularly the intermediate ramus, which can form a neural plexus around the facial a. They may follow a submandibular course, before but also after crossing the facial vessels. They are difficult to classify because of their great variability.

Although rare, ischemic necrosis of the head of the radius after fracture is a theoretic possibility. The epiphyseal vascularisation of the proximal end of the radius was studied by dissection and diaphanisation techniques. The main extra-osseous supply is derived from epiphyseo-metaphyseal arteries given off by the recurrent radial a. and the first collateral of the ulnar a. These, to the number of three or four, anastomose together in a peri-cervical arterial circle continuous with the periosteal vessels of the shaft. From the proximal part of this network there arise three main intra-epiphyseal branches, which traverse the head, but nearly the entire periphery of the osteochondral junction is the site of small periosteal branches penetrating the head, though to no great depth. When the head of the radius is fractured, the commonest displacement is posterolateral, and the main vessel-bearing periosteal layer probably remains intact.

The objective of this prospective innovative treatment is to section the pain pathways carried by sympathetic lumbar rami communicantes to achieve lasting pain relief of refractory low back pain.From December 2005 to September 2008, nine patients were operated by bilateral section of rami communicantes for a refractory low back pain. As a diagnostic and predictive test, all patients had, before surgery, a local anaesthetic infiltration of the sympathetic trunk at L2 performed with computed tomography guidance. Surgery is indicated if the tests lead to a reduction in pain of at least 50 %. The procedure, using a retroperitoneal laparoscopic approach, consisted to identify the sympathetic trunk and to section all lumbar rami communicantes from L1 to L2.No intraoperative complications were observed. The mean postoperative follow-up was 29 ± 15 months. At the last follow-up, only 22 % (2/9) patients had an improvement of their low back pain with this surgery but with a minimal effect (30 and 50 % reduction of pain). An improvement of quality of life was observed in 33 % (3/9) of cases. Due to persistent pain, four patients had a spinal cord stimulation after this surgery.Section the pain pathways carried by sympathetic lumbar rami communicantes for refractory low back pain improved 22 % of patients at the last follow-up of 29 months.

BACKGROUND Schwannoma is a rare benign tumor of peripheral nerves arising from Schwann cells of the ubiquitous nerve sheath. OBJECTIVE To describe the operative steps and technical aspects of robotic laparoscopic resection of pelvic schwannoma. METHODS We describe 2 patients with pelvic schwannoma: a 34-year-old woman with schwannoma of the right lumbosacral trunk and a 58-year-old woman with schwannoma of a left S1 nerve. Pain was the main symptom in both patients. The diagnosis was confirmed by magnetic resonance imaging and nerve biopsies. Both patients were operated on by robotic laparoscopy. RESULTS Lesions were totally enucleated after incising the epineurium. After dissection of the schwannoma, the vascular pedicle and nerve fascicles involved were identified, coagulated, and then sectioned. The remaining fascicles of the nerve were preserved. The postoperative course was uneventful in both patients. With follow-up of 9 and 13 months, both patients obtained complete pain relief with no neurological sequelae. CONCLUSION Robotic laparoscopic resection of pelvic nerve tumors such as schwannomas is technically feasible.

Aims In some patients, with refractory chronic pelvic and perineal pain, pain and quality of life are barely alleviated despite optimal medical treatment, infiltrations and surgical release of the pudendal nerve. The management of these patients is complex, especially after failure of neuromodulation techniques (spinal cord stimulation. S3 nerve root stimulation and direct stimulation of the pudendal nerve). We report the first two cases illustrating the value of motor cortex stimulation (MCS), in this new indication. Methods The history, decision-making process, intraoperative findings and results of this technique are presented. The perineal cortical area was identified by intraoperative motor evoked potentials in the external anal sphincter, confirming its location in the primary motor cortex between the inferior and superior limb positions. As predictive value of repetitive transcranial magnetic stimulation (rTMS) in the identification of responders to MCS for pain is now established, we performed pre-operative rTMS sessions for both patients. Results The first patient was a 74-years-old woman who reported an 11-year history of left lateral perineal pain. The second patient was a 45-year-old woman who reported a 4-year history of perineal pain following hysterectomy with ovariectomy. After respectively 40 months and 19 months of follow up, both patients reported an improvement of pain ranging from 40 to 50%. Time to onset of pain on sitting was markedly improved from a few minutes to 90 minutes, and largely contributing to improvement of activities of daily living and of quality of life. Conclusion These two first cases suggest that motor cortex stimulation constitutes a new treatment for refractory pelvic and perineal pain, and should be considered after failure of conventional neuromodulation techniques, especially spinal cord stimulation. Neurourol. Urodynam. 32: 53–57, 2013. © 2012 Wiley Periodicals, Inc.

Ciliary ganglion is a pre-visceral vegetative ganglion, relay of ocular bulb vegetative pathways, concerning three types of fibers: parasympathetic, sympathetic and somatosensory. The objective of this study was to describe the different patterns of distribution of those fibers around the ciliary ganglion to explain rare post-traumatic or postoperative ocular symptoms. Dissection of 20 orbits, from cavernous sinus to ocular bulb, after intravascular injection of colored latex. Concerning afferents, or roots, three dispositions have to be described: all of them were identified (55 %); parasympathetic root was absent and ciliary ganglion was attached directly to the inferior branch of the oculomotor nerve (25 %); sympathetic root was absent (20 %). Somatosensory root, coming from nasociliary nerve, was constant. Efferents (short ciliary nerves), including these three types of fibers, were variable in number but always constituted two bundles. The absence of identifiable parasympathetic root, resulting in a close relationship between ciliary ganglion and the inferior branch of the oculomotor nerve, could be a possible explanation of postganglionic mydriasis following blow-out orbital floor fracture or surgical repair of this type of fracture. The absence of sympathetic root is due to a forward retro-orbital connection between internal carotid plexus and ophthalmic nerve within cavernous sinus, corresponding to gray rami communicans.

The aim of this study was to describe the arterial supply of the coracoid process and to define its possible involvement in complications of Latarjet procedure.Five shoulder dissections were performed to highlight the extraosseous blood supply of the coracoid process. Postmortem arteriographies of the upper limb were performed. Diaphanization of a scapula enabled to view its intraosseous blood supply.The vertical part of coracoid process was supplied by supra-scapular artery, and the horizontal part by branches of the axillary artery.This anatomical study has shown that the coracoid process had its own blood supply. During the Latarjet procedure, vascular sacrifices are mandatory to allow coracoid process transfer to the scapular neck. Such sacrifices could explain lysis or non-union of the coracoid process after Latarjet procedure. Preservation of axillary artery branches supplying horizontal part of the coracoid process could be a possible solution to prevent non-union and lysis of the bone transfer.

Among conjoined twins (1 out 50000 births), thoracopagus occurs most frequently and is generally lethal. Our anatomical study of five sets of sternopagus twins (3 female, 2 male) was performed to determine the ability of prenatal sonography to detect these anomalies. Autopsy in four cases revealed identical malformations: common sternum, single malformed heart, joined hepatic parenchyma, and a common small bowel leading to a cystic dilatation situated on the ileal segment at the end of the superior mesenteric artery. The diagnosis of conjoined twins was made in all cases by prenatal sonography at the mean time of 24.6 gestation weeks (range 19-34). The malformations detected by prenatal sonography were a single cardiac mass (all cases), joined hepatic parenchymas (3 cases), and an ileal cystic dilatation (1 case). Pregnancy was terminated in four cases. In one case cesarean delivery was performed, and the infants died 48 hours later. Prenatal sonography currently seems to be the best examination for diagnosis of sternopagus twins and the detection of lethal malformations thus allowing interruption of pregnancy.

The incidence of pelvic pain after placement of a suburethral sling for incontinence ranges between 0% and 30%. The management of this chronic pain after suburethral sling placement is complex and to our knowledge no consensus has been reached. We evaluated the functional results after removal of the suburethral tape responsible for chronic pelvic pain.From November 2004 to August 2009, 32 patients undergoing removal of suburethral tape causing chronic pelvic and perineal pain at our department were prospectively followed. Patients were divided according to the type of suburethral sling into the transobturator tape group (15 patients) and the tension-free vaginal (retropubic) tape group (17 patients). In the TVT group tape removal was performed using transperitoneal laparoscopy in every patient. In the TOT group tape removal was performed via a transvaginal approach possibly associated with a unilateral or bilateral incision in the proximal part of the thigh. Pain was evaluated by a visual analogue scale from 0-no pain to 10-maximal pain.The surgical exploration of suburethral tape responsible for chronic, treatment refractory pelvic pain revealed in most cases an abnormal tape position or excessive tape traction. In the overall population tape removal provided improvement of pain (at least 50% improvement of the visual analogue scale score) in 68% with a mean followup of 10 months. Mean visual analogue scale score was 7.3 +/- 1.5 before surgery and 3.4 +/- 3 after surgery. However, recurrence of incontinence was observed in 22% of cases. No significant difference was demonstrated in terms of functional results according to the type of tape insertion.The surgical removal of suburethral tape improved pain in 68% of patients but with a risk of recurrence of urinary incontinence in 22%.

Objective Obturator neuralgia consists of pain radiating from the obturator nerve territory to the inner thigh. Methods We report a case of idiopathic obturator neuralgia resulting from compression of the obturator nerve in the obturator canal, causing a case of nerve entrapment syndrome. The pain was characterized by its localization in the inguinal region and anterointernal side of the thigh, going down to the internal side of the knee. It was worse when standing or in a monopodal stance. Walking caused pain and a limp. Results The diagnosis was confirmed by an analgesic block. The analgesic was infiltrated using a posterior approach and computer-assisted tomography, allowing the quality and specificity of the infiltration to be judged. Conclusion We describe, for the first time, a treatment of obturator neuralgia by a minimally invasive laparoscopic approach. This involved an obturator nerve neurolysis and section of the internal obturator muscle and the obturator membrane.

Neuropathic perineal pains are generally linked to suffering of the pudendal nerve. But some patients present pains described as a type of burning sensation located more laterally on the anal margin and on areas including the scrotum or the labiae majorae, the caudal and medial parts of the buttock and the upper part of the thigh. These pains extend beyond the territory of the pudendal nerve. It is interesting to note that the inferior cluneal nerves are responsible for the cutaneous sensitivity in the inferior part of the buttock. We wanted to check if these nerves, or some of their branches, could be responsible for such pains. An anatomic study, containing six dissections on corpse, has been conducted. The inferior cluneal nerves, emerging from the posterior femoral cutaneous nerve have some branches joining the perineum, especially by a perineal ramus. However, two conflict areas have been identified on the path of these nerves and on the perineal ramus: one at the level of the sacrotuberal ligament, and the other being the passage under the ischium. Two surgical approaches have been established from these observations with the aim of suppressing the conflicts.

Background: We assess that pudendal neuralgia is a tunnel syndrome due to a ligamentous entrapment of the pudendal nerve and have treated 400 patients surgically since 1987. We have had no major complication. We conducted a randomized controlled trial to evaluate our procedure. Methods: A sequential, randomized controlled trial to compare decompression of the pudendal nerve with non-surgical treatment. Patients aged 18–70, had chronic, uni/bilateral perineal pain, positive temporary response to blocks at the ischial spine and in Alcock's canal. They were randomly assigned to surgery ( n =16) and control ( n =16) groups. Primary end point was improvement at 3 months following surgery or assignment to the non-surgery group. Secondary end points were improvement at 12 months and at 4 years following surgical intervention. Results: A significantly higher proportion of the surgery group was improved at 3 months. On intention-to-treat analysis 50% of the surgery group reported improvement in pain at 3 months versus 6.2% of the non-surgery group ( p =.0155); in the analysis by treatment protocol the figures were 57.1% versus 6.7% ( p =.0052). At 12 months, 71.4% of the surgery group compared with 13.3% of the non-surgery group were improved, analyzing by treatment protocol ( p =.0025). Only those randomized to surgery were evaluated at 4 years: 8 remained improved at 4 years. No complications were encountered. Conclusions: In this study we demonstrate that decompression of the pudendal nerve is an effective and safe treatment for cases of chronic pudendal neuralgia that have been unresponsive to analgesia and nerve blocks. Following surgery, other medical interventions may be necessary.

✓ This 7-year-old boy with Hajdu—Cheney syndrome presented with cervical syringomyelia related to rapidly progressing platybasia. Decompressive craniectomy provided temporary improvement, and his clinical status was eventually stabilized after external immobilization, according to findings at 2.5 years of follow up. In a review of the literature the authors found 57 cases of the syndrome, only three of which were associated with syringomyelia. The youth of the patient, the severe form and rapid course of the disease, and the very specific anatomical conditions related to cranial and facial deformities raised various therapeutic problems.

Schwannomas are benign nerve sheath tumours most often associated with the cranial nerves and the peripheral nerve system of the neck and extremities. Pelvic schwannomas are rare, with only about 25 cases reported. We report the case of a 34-year-old man referred for worsening pain of 10 years duration involving the right testicle and right penile shaft. Magnetic resonance imaging discovered a well-circumscribed pelvic tumour of 3.2 × 2.8 × 3.2 cm. Considering the possible complications involved in exposing the pudendal nerve during surgical resection, we performed an extensive literature search to aid preoperative planning. The most commonly described surgical approach for pelvic schwannomas has been open median laparotomy with transperitoneal dissection. To our knowledge, pudendal schwannomas have never been described in the literature. However, after considering the location and characteristics of the tumour, we chose laparoscopy because it offers the advantages of better visualization of anatomical structures with minimal invasiveness and faster recovery. At the 3-week follow-up, the patient described a significant decrease in pain and normal neurological and urological examinations.

Low back pain is frequent and results in major disability for patients. This anatomical study was done to understand mechanisms involved in that pain. Two kinds of innervation are present in the lumbar spine: one depends on the somatic nervous system and the other on the sympathetic nervous system. The sympathetic nerves are the sinu-vertebral nerves and the rami communicantes which innervate the intervertebral disc, the ventral surface of the dura mater, the longitudinal dorsal ligament and the longitudinal ventral ligament. The sinu-vertebral nerve was described first by Luschka in 1850. This nerve is implicated in diffuse low back pain because of its pathway and its sympathetic component. This nerve cannot directly reach a somatic element at each level of the lumbar spine, so must first reach the L2 spinal ganglion. Thus, there is a "hole" in the somatic innervation between L3 and L5 because the dorsal nerves do not reach the skin at these levels. The pain therefore takes another route through the sympathetic system. Discogenic pain is mediated by the sinu-vertebral nerves, and through the rami communicantes reaches the L2 spinal ganglion. Anatomical and clinical features reinforce this hypothesis. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server at http://dx.doi.org/10.1007/s00276-002-0084-8 .

The aim of this study was to define the anatomic characteristics of the principal arterial source of the atrioventricular node, known as the artery of the atrioventricular node. Forty hearts were studied by various anatomic and radiologic methods: dissection, injection-dissection, injection-corrosion and injection-radiography, but only 23 results were interpretable. The right coronary artery represented the commonest arterial source of the atrioventricular node (21/23 hearts) but numerous variations in the origin and topography of the nodal artery were found.

A comparative study of serial anatomic sections in the transverse, frontal and sagittal planes with corresponding MRI sections of the pelvis allowed the authors to define the most suitable sectional planes and MRI modes for a morphologic study of the levator ani muscle. This study shows the value of MRI examination in the assessment of anorectal malformations.

The internal thoracic a. is much used in cardiac surgery because of its anatomic position, but its mobilisation may lead to devascularisation of the sternum. The aim of this study was to establish a precise systematisation of the vascularisation of the sternum by means of dissections and radiography after injection of contrast medium in 15 subjects. It is based on the internal thoracic a. and its collaterals, which form multiple anastomoses. This anatomic basis provides an understanding of the problems of the devascularisation (partial and temporary) and the infections that may occur following the use of one or both internal thoracic aa. during coronary bypass operations. However, it should always be regarded as the graft of choice, given the longevity of these bypasses.

La frequente lesion du RMM lors de la chirurgie cervico-faciale est a l'origine de nombreuses tentatives de systematisation de ce rameau. Toutes concluent a son extreme variabilite qui explique sa vulnerabilite.

The authors describe the anatomical basis of splenorenal anastomosis via the retroperitoneal approach. This technique can be used in cases where the transperitoneal approach is contraindicated.

The action of the omohyoid muscle on the hemodynamics of the internal jugular vein is controversial. For some authors, contraction of this muscle, by tightening the cervical fascia, promotes jugular venous return. For others, contraction of this muscle compresses the jugular vein in its cervical path. With this latter point in mind, the hemodynamics of the internal jugular vein have been studied in its cervical path by echography in 10 healthy volunteers. One hundred twenty measurements of the venous surface were made at rest, with the mouth open and during deep inspiration. In the last 2 situations, evidence of a significant increase in the venous surface was found above the omohyoid muscle. These data confirm the role of compression of the vein by the omohyoid muscle, leading to modifications in intracerebral venous hemodynamics, which can be affected in yawning.

Ce travail montre l'originalite du lobe caude due a son origine embryologique particuliere. Morphologiquement, les PC et PP sont constants et separent 2 territoires independants. Cette separation retrouvee en anatomie comparee est importante puisqu'elle autorise l'exerese isolee d'une partie de ce lobe caude.