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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.

O manejo do solo em cultivos perenes, como pomares, influencia a erosão hídrica. O presente estudo avaliou as perdas de solo e água sob chuva simulada em um Latossolo, em pomar de maçã, entre os meses de agosto de 2007 e abril de 2008, na estação experimental de fruticultura de clima temperado da Embrapa Uva e Vinho, em Vacaria (RS). O trabalho foi conduzido em parcelas experimentais de 3,5 x 11 m, sob chuvas com 1 h de duração e intensidade constante ao longo delas, com variação de 70 a 88 mm h-1 entre uma chuva e outra. Os sistemas de manejo estudados foram: 1) capina manual sob a copa das plantas e solo coberto com gramíneas e leguminosas no restante da área (ST); 2) aveia não dessecada, em que as sementes foram incorporadas ao solo, com capina manual em toda a área, dois meses antes do início dos testes de chuva (AN); 3) aveia dessecada quimicamente sete dias antes do início dos testes de chuva, em que as sementes foram incorporadas ao solo com enxada rotativa em toda a área, dois meses antes do início dos testes (AD); e 4) solo sem cobertura, em que a vegetação, após ter sido dessecada, foi removida da superfície do solo em toda a área com capina manual, um dia antes de iniciar os testes de chuva (SC). A forma de manejo da superfície do solo e o número de chuvas influenciaram a erosão hídrica; as perdas de solo variaram amplamente, enquanto as perdas de água apresentaram menor variação. Apesar da mobilização do solo para implantação de aveia, os tratamentos AN e AD com esse cultivo mostraram a mesma eficácia de controle da erosão em relação ao tratamento ST, em que o solo foi mobilizado apenas sob a copa das plantas. A eliminação da cobertura do solo no tratamento SC aumentou expressivamente as perdas de solo em relação aos tratamentos com cobertura; no que se refere às perdas de água, a diferença foi menor. O tempo de ocorrência do escoamento superficial influenciou a perda de solo; observou-se aumento dessa variável com o aumento do tempo de enxurrada até certo momento, a partir do qual diminuiu, independentemente do tratamento; a perda de água aumentou até certo momento e estabilizou. Houve relação inversa entre razão de perda de solo e razão de perda de água, independentemente do tipo de cobertura do solo e do sistema de manejo sob as macieiras. O modelo exponencial ajustou-se a essa relação.

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.

Resume Le disque intervertebral (DIV) est une structure anatomique complexe constituee d’une zone gelatineuse a peu pres centrale, le nucleus pulposus (NP), entouree par une structure annulaire de type ligamentaire, l’annulus fibrosus (AF) ; et separee des plateaux vertebraux par des plaques cartilagineuses (PC) qui constituent la principale voie nutritive de ce noyau. Les caracteristiques cellulaires et biochimiques de ces tissus en determinent les proprietes biomecaniques. Le noyau pulpeux agit comme un repartiteur des pressions appliquees au DIV, ce qui permet le maintien relatif de sa hauteur par la mise en tension des fibres de l’anneau fibreux. Les importantes contraintes subies par le DIV impliquent des phenomenes de viscoelasticite mis en jeu rapidement, mais egalement des phenomenes plus lents d’echanges corporeo-discaux lies a la porosite des PC.

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

O fósforo é um elemento químico chave para a qualidade da água, agindo principalmente como gatilho desencadeador das florações algais. A principal fonte de fósforo nas pequenas bacias rurais advém da agricultura feita nas encostas das bacias, podendo chegar de várias formas ao corpo d’água, porém as formas mais impactantes são o fósforo reativo total e o dissolvido. A forma dissolvida é a que apresenta maiores riscos pois pode percorrer distâncias comparativamente maiores do que o fósforo reativo nos sedimentos em suspensão que podem acabar depositados ao longo do caminho. Portanto, este trabalho visa avaliar se diferentes coberturas do solo por culturas anuais podem interferir no arraste destas formas de fósforo, afetando o risco da degradação dos recursos hídricos das pequenas bacias rurais. Apesar de não ter havido diferença significativa entre os tratamentos, verificou-se sazonalidade ao longo do experimento representando uma estação de cultivo. Isto significa que houve variação do nível de risco, uma vez que, no terço inicial das primeiras chuvas, o risco de arraste de fósforo na enxurrada foi mais elevado em relação a períodos chuvosos mais distantes da época de plantio/fertilização, tornando-se possível avaliar o risco à bacia de forma sazonal e não anual.

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.

Resume La decouverte d’un tronc cœliomesenterique commun est souvent fortuite au cours d’une exploration morphologique ou vasculaire. A propos d’un cas de cette rare variation anatomique arterielle, nous en rappelons les caracteristiques et les differents types. Nous soulignons l’interet de ne pas meconnaitre cette variation en radiologie interventionnelle et en pathologie vasculaire. Dans notre observation, le tronc cœliomesenterique presente a son origine un ostium ovalaire de 14 mm de grand axe, un trajet median de 8 mm et une terminaison par division en tronc commun hepatosplenogastrique et en tronc arteriel mesenterique superieur. Il s’agit d’un tronc cœliomesenterique de type I de la classification d’Higashi, disposition la plus frequente de cette variation arterielle.

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.

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.

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 cropping system influences the interception of water by plants, water storage in depressions on the soil surface, water infiltration into the soil and runoff. The aim of this study was to quantify some hydrological processes under no tillage cropping systems at the edge of a slope, in 2009 and 2010, in a Humic Dystrudept soil, with the following treatments: corn, soybeans, and common beans alone; and intercropped corn and common bean. Treatments consisted of four simulated rainfall tests at different times, with a planned intensity of 64 mm h-1 and 90 min duration. The first test was applied 18 days after sowing, and the others at 39, 75 and 120 days after the first test. Different times of the simulated rainfall and stages of the crop cycle affected soil water content prior to the rain, and the time runoff began and its peak flow and, thus, the surface hydrological processes. The depth of the runoff and the depth of the water intercepted by the crop + soil infiltration + soil surface storage were affected by the crop systems and the rainfall applied at different times. The corn crop was the most effective treatment for controlling runoff, with a water loss ratio of 0.38, equivalent to 75 % of the water loss ratio exhibited by common bean (0.51), the least effective treatment in relation to the others. Total water loss by runoff decreased linearly with an increase in the time that runoff began, regardless of the treatment; however, soil water content on the gravimetric basis increased linearly from the beginning to the end of the rainfall. O sistema de cultivo influencia a interceptação de água pelas plantas, a armazenagem de água nas depressões do terreno, a infiltração de água no solo e o escoamento superficial. Este trabalho objetivou quantificar alguns processos hidrológicos em sistemas de cultivo do solo realizados em contorno no declive, em 2009 e 2010, em um Cambissolo Húmico alumínico, cuja área foi mantida sem preparo prévio do solo, nos seguintes tratamentos: solteiros - milho, soja e feijão; e consorciados - milho e feijão. Os tratamentos foram submetidos a quatro testes de chuva simulada, em épocas distintas, com intensidade planejada de 64 mm h-1 e duração de 90 min. O primeiro teste foi aplicado 18 dias após a semeadura e, os demais, aos 39, 75 e 120 dias, após o primeiro. Os diferentes momentos de aplicação das chuvas e os diferentes estádios do ciclo das culturas influenciaram o teor de água no solo antecedente às chuvas, o tempo de início e o de pico da enxurrada e, com isso, os processos hidrológicos de superfície. A lâmina de enxurrada e a de água interceptada pela vegetação + infiltrada no solo + armazenada superficialmente no solo sofreram a influência dos sistemas de cultivo e das chuvas aplicadas nas diferentes épocas. O cultivo de milho foi o tratamento mais eficaz no controle do escoamento superficial, com uma razão de perda de água de 0,38, equivalente a 75 % da razão de perda de água apresentada pelo feijão (0,51), que foi o tratamento menos eficaz em relação aos demais sistemas de cultivo. A perda total de água na forma de enxurrada decresceu linearmente com o aumento do tempo de início da enxurrada, independentemente do tratamento, enquanto o teor de água no solo em base gravimétrica aumentou linearmente do início ao final da chuva.

The cropping system influences the interception of water by plants, water storage in depressions on the soil surface, water infiltration into the soil and runoff. The aim of this study was to quantify some hydrological processes under no tillage cropping systems at the edge of a slope, in 2009 and 2010, in a Humic Dystrudept soil, with the following treatments: corn, soybeans, and common beans alone; and intercropped corn and common bean. Treatments consisted of four simulated rainfall tests at different times, with a planned intensity of 64 mm h-1 and 90 min duration. The first test was applied 18 days after sowing, and the others at 39, 75 and 120 days after the first test. Different times of the simulated rainfall and stages of the crop cycle affected soil water content prior to the rain, and the time runoff began and its peak flow and, thus, the surface hydrological processes. The depth of the runoff and the depth of the water intercepted by the crop + soil infiltration + soil surface storage were affected by the crop systems and the rainfall applied at different times. The corn crop was the most effective treatment for controlling runoff, with a water loss ratio of 0.38, equivalent to 75 % of the water loss ratio exhibited by common bean (0.51), the least effective treatment in relation to the others. Total water loss by runoff decreased linearly with an increase in the time that runoff began, regardless of the treatment; however, soil water content on the gravimetric basis increased linearly from the beginning to the end of the rainfall.

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.

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.