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Purpose of Review: The aim of this article is to review considerations and efficacy of third-line treatments for pediatric non-neurogenic bladder dysfunction, including Botulinum toxin A (BoTNA), Posterior Tibial Nerve Stimulation (PTNS), and Sacral Neuromodulation (SNM). Recent Findings: Federal Drug Administration approval for use of beta-3-agonists in overactive detrusor activity in pediatric patients may provide an additional step prior to third-line therapies. New long-term data on pediatric SNM efficacy, complications, and revision rates will provide valuable information for counseling families. Summary: BoTNA offers a safe and efficacious treatment to decrease detrusor contractility and improve bladder capacity but is limited by the half-life of BoNTA agent. Percutaneous or transcutaneous PTNS offers improved voided volumes or cure in some patients but is time-intensive. SNM can be utilized in a variety of LUTD pathology with high success rate and cure but should consider cumulative anesthetic and fluoroscopic exposures for battery replacements and re-positioning for patient growth. [ABSTRACT FROM AUTHOR]

Background and Aims: Ultrasound-guided sacral plexus block has been used for anaesthesia and analgesia in lower limb surgeries. This study aimed to compare the block performance characteristics after ultrasound-guided (USG) sacral plexus nerve block (SNB) using the parasacral parallel shift (PSPS) approach versus the classical approach in patients undergoing orthopaedic below-knee limb surgeries. Methods: In this randomised study, 144 adult patients were randomised to receive USG SNB either by the classical approach (Group C) or the PSPS approach (Group P). A fixed dose of 20 ml of 0.5% ropivacaine was administered. Patients also received USG femoral nerve block with 10 ml of 0.5% ropivacaine. The primary outcome was the scanning time between the two groups. Secondary outcomes were the needling time, sensory and motor block onset and postoperative analgesic characteristics between the two groups. A P value of

Objective: To describe the sonomorphological changes and appearance of deep endometriosis (DE) affecting the nervous tissue of the sacral plexus (SP). Methods: This was a retrospective study of symptomatic patients who underwent radical resection of histologically confirmed DE affecting the SP and who had undergone preoperative transvaginal sonography (TVS) between 2019 and 2023. Lesions were described based on the terms and definitions of the International Deep Endometriosis Analysis (IDEA), International Ovarian Tumor Analysis (IOTA) and Morphological Uterus Sonographic Assessment (MUSA) groups. A diagnosis of DE affecting the SP on TVS was made when the sonographic criteria of DE were visualized in conjunction with fibers of the SP and the presence of related symptoms corresponding to sacral radiculopathy. Clinical symptoms, ultrasound features and histological confirmation were analyzed for each patient included. Results: Twenty‐seven patients with DE infiltrating the SP were identified in two contributing tertiary referral centers. Median age was 37 (range, 29–45) years and all patients were symptomatic and presented one or more of the following neurological symptoms: dysesthesia in the ipsilateral lower extremity (n = 17); paresthesia in the ipsilateral lower extremity (n = 10); chronic pelvic pain radiating in the ipsilateral lower extremity (n = 9); chronic pain radiating in the pudendal region (n = 8); and motor weakness in the ipsilateral lower extremities (n = 3). All DE lesions affecting the SP were purely solid tumors in the posterior parametrium in direct contact with, or infiltrating, the S1, S2, S3 and/or S4 roots of the SP. The median of the largest diameter recorded for each of the DE nodules was 35 (range, 18–50) mm. Echogenicity was non‐uniform in 23 (85%) of the DE nodules, with all but one of these nodules containing hyperechogenic areas. The shape of the lesions was irregular in 24 (89%) cases. Only one lesion exhibited a lobulated form, with all other irregular lesions showing a spiculated appearance. An acoustic shadow was produced in 20 (74%) of the nodules, all of which were internal. On color or power Doppler examination, 21 (78%) of the nodules showed no signal (color score of 1). The remaining six (22%) lesions showed a minimal color content (color score of 2). According to pattern recognition, most DE nodules were purely solid, non‐uniform, hypoechogenic nodules containing hyperechogenic areas, with internal shadows and irregular spiculated contours, and were poorly vascularized on color/power Doppler examination. Conclusion: The ultrasound finding of a parametrial, unilateral, solid, non‐uniform, hypoechogenic nodule with hyperechogenic areas and possible internal shadowing, as well as irregular spiculated contours, demonstrating poor vascularization on Doppler examination in proximity to or involving the structures of the SP, indicates DE affecting the SP. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Junwei Zheng,1,2 Yan Mi,3 Jinghan Liang,1 Huili Li,1 Peiqi Shao,1 Hong Wen,1 Yun Wang1 1Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China; 2Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei Province, People’s Republic of China; 3Department of Anesthesiology, Tumour Hospital, Zhengzhou University, Zhengzhou, Henan Province, People’s Republic of ChinaCorrespondence: Yun Wang; Hong Wen, Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China, Tel +86-10-85231330, Fax +86-10-65077808, Email wangyun129@ccmu.edu.cn; wendoctorhong@sina.comPurpose: Total hip arthroplasty (THA) is often associated with moderate to severe pain. The present study compared the efficacy of circum-psoas block (CPB) with supra-inguinal fascia iliaca block (SIFIB) for postoperative analgesia in patients undergoing THA.Patients and Methods: In this randomized trial, sixty-four patients undergoing THA were allocated randomly to the CPB group or SIFIB group with 40 mL of 0.3% ropivacaine. The primary outcome was dynamic pain score at 6 h postoperatively. Secondary outcomes included dynamic pain scores at 12, 24 and 48 h; static pain scores; sensory and motor block; opioid consumption; time to first opioid request; length of hospital stay; patient satisfaction; and adverse events.Results: CPB patients showed significantly lower dynamic pain scores at 6 (3.11 ± 0.66 vs 4.47 ± 0.74, respectively; P = 0.000), 12 (2.52 ± 0.73 vs 3.53 ± 0.85, respectively; P = 0.000) and 24 h (2.30 ± 0.57 vs 2.87 ± 0.71, respectively; P = 0.001) after surgery, as well as lower static pain scores at 6 and 12h (P = 0.001 and P = 0.033 respectively) than SIFIB patients. Lower opioid consumption was observed in the CPB group at 24 and 48 h (P = 0.000, both) than in the SIFIB group. Patients in the CPB group reported improved quadriceps strength at 6 and 12 h (P = 0.000, both), as well as better muscle strength of hip flexion at 6, 12 and 24 h (P = 0.000, P = 0.000 and P = 0.025 respectively). Compared with SIFIB, CPB was associated with increased sensory block coverage at 6, 12 and 24 h (P = 0.000, P = 0.000, and P =0.022, respectively).Conclusion: CPB has a greater potential to alleviate postoperative pain and improve recovery in THA patients than SIFIB.Keywords: total hip arthroplasty, lumbar plexus, sacral plexus, regional anesthesia

Objective: To investigate the feasibility of identifying and measuring the normal sacral plexus (SP) on gynecological transvaginal ultrasound (TVS) examination. Methods: This was a prospective observational study conducted at a single tertiary gynecological referral center, including consecutive women undergoing TVS for various indications between November 2021 and January 2022. A standardized assessment of the pelvic organs was performed and the presence of any congenital or acquired uterine pathology or ovarian abnormality was recorded. Visualization of the right and left SP was attempted in all cases. The success rate and the time needed to identify the SP were recorded and measurements of the SP were made. Results: A total of 326 patients were included in the study. In all women, the SP was identified successfully on at least one side. SP were visualized bilaterally in 317 (97.2% (95% CI, 94.4–98.5%)) women. Only the right SP was seen in 3/326 (0.9% (95% CI, 0.2–2.7%)) and only the left in 6/326 (1.8% (95% CI, 0.6–4.0%)) (P = 0.5048). There was no significant difference in the median time required to visualize the right vs left SP (9.0 (interquartile range (IQR), 8.0–10.0) s vs 9.0 (IQR, 8.0–10.0) s; P = 0.0770). The median transverse diameter of the right SP was 15.0 (IQR, 14.2–15.6) mm and that of the left SP was 14.9 (IQR, 14.4–15.6) mm. Conclusions: We describe a novel method which allows for the consistent and rapid identification of the SP on TVS. Integrating assessment of the SP into routine pelvic TVS may be helpful particularly for women suffering from deep endometriosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background: Transvaginal suspension procedures often use the sacrospinous ligament (SSL), which attaches onto the ischial spine (IS). However, nerve-related sequelae (e.g., sciatic nerve injury) following such procedures have been reported. Therefore, the current anatomical study was performed to better understand these relationships. Additionally, three case illustrations of patients with injury to the sciatic nerve following sacrospinous ligament suspension procedures are included to exemplify the significance of a thorough knowledge of this anatomy. Methods: In 20 human adult cadavers (40 sides), a gluteal dissection was performed to expose the IS and SSL and regional nerves near the greater sciatic foramen. Measurements between the IS and SSL were made between these structures and surrounding nerves. Results: The average distance between the IS and sciatic nerve was 1.4 cm. From this bony part, the average distance to the S1 and S2 ventral rami was 3.1 cm and 1.9 cm, respectively. From the IS to the lumbosacral trunk, pudendal nerve, nerve to obturator internus, and superior gluteal nerve, the mean distance was 4 cm, 0.5 cm, 0.7 cm, and 4.5 cm, respectively. From the SSL to the lumbosacral trunk, S1 ventral ramus, and S2 ventral ramus, there was an average distance of 4.2 cm, 1.6 cm, and 0.8 cm, respectively. Statistically, in females, the distances from the IS and SSL to the sciatic nerve, lumbosacral trunk, superior gluteal nerve, and S1 and S2 ventral rami were shorter when compared to males. Conclusion: An improved understanding of the relationship between the SSL and IS and nerves near the greater sciatic foramen can lead to fewer intraoperative complications during approaches to various peripheral nerves in this region. Lastly, these relationships might help better understand the nerve injuries following pelvic suspension procedures that use the SSL. [ABSTRACT FROM AUTHOR]

The study of segmental innervation may be of practical interest, as pathological processes involving organs and tissues can be caused by damage to both peripheral and individual segmental nerves. Also, the occurrence of a pathological condition of the pelvic limb structures can be associated with various injuries, damage to the spinal cord, roots and segmental nerves of the sacral spine. The aim of the experimental research was to study the segmental formation of the main nerves of the sacral plexus – n. ischiadicus, n. tibialis, n. peroneus communis in cats. Unilateral extravertebral ganglioectomy of the lumbosacral segments – L 4, L5, L6, L7, S1, S2 was performed for the study. Samples of the main nerves were examined in polarized light to detect signs of Wallerian's degeneration at x400 magnification. This method allows you to easily distinguish degenerated nerve fibers at different stages of degeneration from normal. The micromorphology of the initial stages of degeneration is characterized by uneven thickening of the fibers, smoothing of the Ranvier nodes, dilated Schmidt-Lanterman notches, an increasein the number of myelin segments. At later stages of Wallerian's degeneration, the following are observed: edema and significant thickening of the myelin sheath, smoothing of fiber contours, formation of ovoids and fragmentary glow of myelin. Statistical analysis of the results was performed using Student's t-test. In the course of research, it was found that in the formation of the main nerves of the sacral plexus: n. ischiadicus, n. tibialis, n. peroneus communis involves 6 segments of the lumbosacral spine - from L4 to S2. These nerves of the sacral plexus are polysegmental, which indicates their compensatory properties. The highest percentage of degenerated nerve fibers for the main nerves of the sacral plexus gives the 6th lumbar segment L6, which is the axial nerve. The obtained results can expand the knowledge of principles of segmentation in anatomy, to become a reference point for sacral regional epidural anesthesia for orthopedic operations on the pelvic limbs, nerve blockade to increase patient comfort in the postoperative period, lumbar puncture, neurotherapy. The method of polarization microscopy can be used as a clinically useful test for peripheral nerve biopsy to assess the state of neurodegenerative changes, monitoring regenerative and neuroprotective effects.

Parasacral ischial plane block is a novel fascial plane approach to sacral plexus. Parasacral ischial plane block is technically less challenging and obviates the need for direct visualisation of sacral plexus. It can reliably be performed in limb-amputated patients where neuromuscular stimulation is less useful. Ten patients of the American Society of Anesthesiologists physical status II-IV, aged between 18 and 70 years, posted for elective lower limb debridement surgeries were enroled in this prospective case series. The time taken to perform the block was ≤4 minutes in all cases. Time taken for full sensory loss was 9 minutes to 15 minutes. None of the patients developed a complete motor blockade till 30 minutes after our observation. None of the patients required intraoperative supplemental analgesia. This block is technically easy, less time-consuming, and provided adequate sensory analgesia in below-knee surgeries. [ABSTRACT FROM AUTHOR]

Parasacral ischial plane block is a novel fascial plane approach to sacral plexus. Parasacral ischial plane block is technically less challenging and obviates the need for direct visualisation of sacral plexus. It can reliably be performed in limb-amputated patients where neuromuscular stimulation is less useful. Ten patients of the American Society of Anesthesiologists physical status II-IV, aged between 18 and 70 years, posted for elective lower limb debridement surgeries were enroled in this prospective case series. The time taken to perform the block was ≤4 minutes in all cases. Time taken for full sensory loss was 9 minutes to 15 minutes. None of the patients developed a complete motor blockade till 30 minutes after our observation. None of the patients required intraoperative supplemental analgesia. This block is technically easy, less time-consuming, and provided adequate sensory analgesia in below-knee surgeries.

Purpose: The cause of the piriformis-related pelvic and extra-pelvic pain syndromes is still not well understood. Usually, the piriformis syndrome is seen as extra-pelvic sciatica caused by the entrapment of the sciatic nerve by the piriformis in its crossing through the greater sciatic foramen. However, the piriformis muscle may compress additional nerve structures in other regions and cause idiotypic pelvic pain, pelvic visceral pain, pudendal neuralgia, and pelvic organ dysfunction. There is still a lack of detailed description of the muscle origin, topography, and its possible relationships with the anterior branches of the sacral spinal nerves and with the sacral plexus. In this research, we aimed to characterize the topographic relationship of the piriformis with its surrounding anatomical structures, especially the anterior branches of the sacral spinal nerves and the sacral plexus in the pelvic cavity, as well as to estimate the possible role of anatomical piriformis variants in pelvic pain and extra-pelvic sciatica. Methods: Human cadaveric material was used accordingly to the Swiss Academy of Medical Science Guidelines adapted in 2021 and the Federal Act on Research involving Human Beings (Human Research ACT, HRA, status as 26, May 2021). All body donors gave written consent for using their bodies for teaching and research. 14 males and 26 females were included in this study. The age range varied from 64 to 97 years (mean 84 ± 10.7 years, median 88). Results: three variants of the sacral origin of the piriformis were found when referring to the relationship between the muscle and the anterior sacral foramen. Firstly, the medial muscle origin pattern and its complete covering of the anterior sacral foramen by the piriformis muscle is the most frequent anatomical variation (43% in males, 70% in females), probably with the most relevant clinical impact. This pattern may result in the compression of the anterior branches of the sacral spinal nerves when crossing the muscle. Conclusions: These new anatomical findings may provide a better understanding of the complex piriformis and pelvic pain syndromes due to compression of the sacral spinal nerves with their somatic or autonomous (parasympathetic) qualities when crossing the piriformis. [ABSTRACT FROM AUTHOR]

Aim: This research was carried out to investigate the lumbar and the sacral plexuses of the Common Pheasant (Phasianus colchicus) is the native bird. Materials and Methods: In the study, 5 female and 5 male pheasants were used. Pheasants were examined macroscopically and morphologically by routine fixation (10% formalin) and dissection method. Nomina Anatomica Avium (1993) was used to avoid confusion arising from naming in the study. Results: The synsacral spinal segments were examined as a whole due to the presence of synsacrum, when examining the plexus lumbalis and plexus sacralis. Generally, it was observed that the plexus lumbalis was shaped by the ventral branches of the 2-4th synsacral spinal nerves. Plexus sacralis was observed to be in the caudal of the plexus lumbalis and it was determined that it consisted of the ventral branches of the 4-8th synsacral spinal segments. Conclusion: As a result, the synsacral spinal nerves involved in the formation of the plexus lumbalis and plexus sacralis in the Common Pheasant (Phasianus colchicus) and the nerves emerging from these plexuses were examined in detail. Similarities and differences between avian species were revealed.

Purpose: The transversalis fascia (TF) encases the quadratus lumborum and psoas major (PM) muscles, respectively, after they split caudalward approximately at the level of the iliac crest. The branches of the lumbar plexus variably exit medially and laterally from the TF-encased PM muscle. We hypothesized that the local anesthetic (LA) injections around the anterolateral edge of PM at the supra-iliac level and into the retro-psoas compartment at the L5/S1 level, which termed as the circum-psoas blocks, could block the lumbar plexus branches. Therefore, here we evaluated the sensory loss caused by the circum-psoas blocks. Methods: A total of 26 patients scheduled for total hip replacement were recruited for the study. After anesthesia induction, the ultrasound-guided circum-psoas blocks were performed in the lateral position with the affected side upward, in which the 0.3% ropivacaine was injected posterior to the TF and around the anterolateral edge of PM muscle at the supra-iliac level (25 mL), and into the retro-psoas compartment at the L5/S1 level (20 mL). The sensory block dermatomes and the muscle strength of quadriceps femoris were evaluated at 2 h or 6 h after surgery, respectively. The postoperative pain scores and opioid consumption were recorded. Results: The median (interquartile range) highest and lowest dermatomes of sensory block were T10 (T9–T10) and S2 (S2–S2), respectively. The muscle strength of the quadriceps femoris evaluated at 6 h post-surgery was 4 (4– 5) points. Total postoperative equivalent milligrams of oral morphine consumption in the first 24 h were 11.3 ± 3.6 mg. Conclusion: The circum-psoas blocks may be a promising approach for postoperative analgesia of hip surgery, since they provide a dermatomal coverage of sensory block from T8– 11 to S1– 3. Clinical Trial Registration: Chinese Clinical Trial Registry, clinical trial number ChiCTR2100051247. [ABSTRACT FROM AUTHOR]

Background and Aims: Ultrasound-guided sacral plexus block has been used for anaesthesia and analgesia in lower limb surgeries. This study aimed to compare the block performance characteristics after ultrasound-guided (USG) sacral plexus nerve block (SNB) using the parasacral parallel shift (PSPS) approach versus the classical approach in patients undergoing orthopaedic below-knee limb surgeries., Methods: In this randomised study, 144 adult patients were randomised to receive USG SNB either by the classical approach (Group C) or the PSPS approach (Group P). A fixed dose of 20 ml of 0.5% ropivacaine was administered. Patients also received USG femoral nerve block with 10 ml of 0.5% ropivacaine. The primary outcome was the scanning time between the two groups. Secondary outcomes were the needling time, sensory and motor block onset and postoperative analgesic characteristics between the two groups. A P value of <0.05 was considered statistically significant., Results: The needling time and the scanning time were significantly lesser in Group P than in Group C ( P < 0.05). Complete sensory and motor nerve blockade of the sciatic nerve was significantly higher in Group P ( P = 0.029). Block performance time, time for sensory block and time for motor block were significantly less in Group P compared to Group C ( P < 0.001). The postoperative analgesic characteristics were comparable between the two groups., Conclusion: The sacral plexus block with ultrasound-guided parasacral parallel shift technique had a lower block performance time with lesser needling and scanning time than the classical approach., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Anaesthesia.)

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

Copyright of Eurasian Journal of Veterinary Sciences is the property of Eurasian Journal of Veterinary Sciences and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article focuses on sacral plexus is derived from the lumbosacral trunk and the first to fourth sacral anterior rami. Topics include the plexus emerges within the pelvis anterior to the piriformis muscle to the presacral fascia, the major branch of the sacral plexus is the sciatic nerve (SN), and clinically relevant branches include the posterior femoral cutaneous nerve (PFCN), and the PFCN provides cutaneous innervation to the posterior thigh with articular branches from the SN.

Objective: To present 10 consecutive, standardized, and reproducible surgical steps allowing complete excision of deep endometriosis nodules infiltrating the parametrium and sacral roots.Design: Surgical video presenting the 10 surgical steps. Local institutional review board approval was not required for this video article, because the video describes a technique and the patient cannot be identified whatsoever.Setting: Endometriosis Center.Patients: Patients undergoing excision of deep endometriosis nodules of the parametrium and sacral roots.Intervention: The excision of deep endometriosis infiltrating the parametrium down to the sacral roots may be performed following 10 steps: complete ureterolysis and removal of ureteral stenosis; opening of the pararectal space in contact with the rectum in a sagittal plane; dissection caudally toward the rectovaginal space, section of the rectovaginal nodule in two separate blocks infiltrating the rectum and vagina, respectively, all the way down to the levator ani muscles; dissection of the presacral space and identification of the superior hypogastric plexus and hypogastric nerve; transverse incision of the peritoneum at the level of the promotorium, extended laterally above the origin of the hypogastric vessels; anterograde dissection of the hypogastric artery and identification of the hypogastric vein; anterograde dissection of the hypogastric vein and opening of Okabayashi space, followed by identification and, when required, ligation of hypogastric vein tributaries; dissection is extended behind the venous network with identification of the pyriform muscles and sacral roots S2, S3, and S4; anterograde dissection of the nerve network and inferior hypogastric plexus, up to the posterior limits of the deep endometriosis nodule; and excision of the deep endometriosis nodule from the posterior limit to the inferior limit in contact with the sacral roots, which should be released or shaved, then to the lateral limit in contact with the pyriform muscle and lateral pelvic wall. Additional steps may be required to remove adjacent infiltration of the vagina, rectum, bladder, or ureters. The movie does not reflect a similar approach in cases of isolated nodules of the sciatic nerves involving a specific lateral dissection plane between the external iliac vessels and the iliopsoas muscle.Main Outcome Measures: Description of 10 successive surgical steps.Results: The 10-step procedure already has been employed in 70 women with deep endometriosis of the parametria involving sacral roots, in whom sensory or motor complaints were not completely relieved by continuous amenorrhea provided by contraceptive pill intake or gonadotropin-releasing hormone analogs. Baseline complaints included somatic pain (85.7%), severe bladder dysfunction (10%), or hydronephrosis (24.3%). Main localizations concerned sacral roots (95.7%), sciatic nerves (7.1%), mid/low rectum (87.1%), and bladder (21.4%). Operative time was 224 ± 94 minutes. Among postoperative complications, we recorded rectovaginal fistulae (14.3%), urinary tract fistulae (4.3%), and bladder dysfunction at 3 weeks (22.9%) and 12 months (5.7%) after the surgery.Conclusions: Laparoscopic excision of deep endometriosis nodules of the parametria involving the sacral roots is a challenging procedure, requiring good anatomic and surgical skills. Teaching such a complex procedure is a delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the hypogastric venous network, preserve as much as possible autonomic nerves and organ function, and successfully excise deep endometriosis nodules. However, transection of the internal iliac artery and vein should not be systematic, as it may adversely affect the vascular supply of the pelvis. Transection of small pelvic splanchnic nerves should be performed only if they actually are included in fibrous nodules, as it may be followed by sexual, bladder, and rectal dysfunction or perineal sensory effects. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and their use should be individualized. [ABSTRACT FROM AUTHOR]

Although posttraumatic mesenteric artery ischemia is attributed to various etiologies, sacral parasympathetic network/mesenteric artery relations have not been studied so far. The primary objective of this study is to elucidate whether there is a relationship between Onuf's nucleus ischemia and mesenteric artery vasospasm following subarachnoid hemorrhage (SAH). This study was conducted on 22 rabbits. The animals were grouped as follows: 5 of animals control, 5 SHAM which saline was given, and 12 animals study group that was homologous blood injected into the spinal subarachnoid space at the Lı level. Neurodegeneration in Onuf's nucleus, axonal degeneration of S2 roots, and mesenteric arteries vasospasm indexes (VSI; Wall surface/Lumen surface), brachias of mesentery arteries in various tissues and ischemic mucosal changes of intestines of all animals were determined histopathologically. Important degenerative changes were detected in axons in S2 roots and Onuf's nucleus in severe mesenteric artery vasospasm observed. The mean degenerated neuron density of Onuf's nucleus (n/mm3), degenerated axon density in S2 roots (n/mm2), and VSI values of mesenteric arteries of control, SHAM, and study groups were estimated as 5.00 ± 1.58, 4.00 ± 1.58, 1.76 ± 0.13; 18.29 ± 4.31, 11.00 ± 2.24, 2.23 ± 0.20; and 135.21 ± 30.75, 117.33 ± 22.11, 2.81 ± 0.44, respectively. Statistical analyses between the VSI values, mucosal ischemic changes degenerated neurons in Onuf's nucleus, and axons in S2 levels were meaningful (p < 0.005). We interestingly noticed that Onuf's nucleus–S2 roots complex degeneration plays an important role in mesenteric artery vasospasm and the development of intestinal ischemic mucosal changes following SAH which has not been extensively mentioned in the literature. • Mesentery artery spasm is a common problem, but diagnosed rarely. • Spinal cord pathologies could be most important factors on the development of mesenteric artery circulation disorders. • The relationship between these two entities are not well established. [ABSTRACT FROM AUTHOR]

Copyright of Der Schmerz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

To show how advanced pelvic Schwannoma can be safely managed with a laparoscopic approach. Demonstration of the laparoscopic technique with narrated video footage. Schwannomas are benign tumors that arise from well-differentiated Schwann cells (glial cells) of peripheral nerve sheaths. Schwannomas are nonaggressive, slow-growing, solitary masses with a low rate of malignant transformation and a low risk of recurrence after resection. They rarely occur in the pelvis, with a reported incidence of 1% to 3%. Tumors involving spinal nerve roots commonly present with radicular pain and nerve compression syndromes (Supplemental Video 1-3). This video shows the management of pelvic Schwannoma originating from the left sacral root S1 by a minimally invasive approach. Laparoscopic nerve-sparing excision of a pelvic Schwannoma. Historically, pelvic schwannomas have been managed mainly by laparotomy. Here, we demonstrate the feasibility and safety of a large pelvic Schwannoma excision by a minimally invasive approach. [ABSTRACT FROM AUTHOR]

Wójcik Gustaw, Pocztarska Agata, Stawińska Teresa. Masywna kalcyfikacja mięśniaków macicy jako przyczyna porażenia splotu krzyżowego – opis przypadku = Massive calcification of uterine fibroids as a cause of sacral plexus palsy - a case study. Journal of Education, Health and Sport. 2016;6(10):331-336. eISSN 2391-8306. DOI http://dx.doi.org/10.5281/zenodo.162889 http://ojs.ukw.edu.pl/index.php/johs/article/view/3950 The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part B item 755 (23.12.2015). 755 Journal of Education, Health and Sport eISSN 2391-8306 7 © The Author (s) 2016; This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. This is an open access article licensed under the terms of the Creative Commons Attribution Non Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 02.10.2016. Revised 02.10.2016. Accepted: 20.10.2016. MASYWNA KALCYFIKACJA MIĘŚNIAKÓW MACICY JAKO PRZYCZYNA PORAŻENIA SPLOTU KRZYŻOWEGO – OPIS PRZYPADKU MASSIVE CALCIFICATION OF UTERINE FIBROIDS AS A CAUSE OF SACRAL PLEXUS PALSY - A CASE STUDY Wójcik Gustaw1,2, Pocztarska Agata1, Stawińska Teresa3 1 Państwowa Szkoła Wyższa im. Papieża Jana Pawła II w Białej Podlaskiej, Wydział Nauk o Zdrowiu i Nauk Społecznych 2 Uniwersytet Medyczny w Lublinie, Katedra Rehabilitacji, Fizjopterapii i Balneoterapii, Zakład Balneoterapii 3 Uniwersytet Medyczny w Lublinie, Katedra Rehabilitacji, Fizjoterapii i Balneoterapii, Zakład Rehabilitacji SŁOWA KLUCZOWE: kalcyfikacja miednicy, mięśniaki macicy, splot krzyżowy, tomografia komputerowa STRESZCZENIE Mięśniaki macicy są jednym z najbardziej powszechnych, występujących u kobiet nowotworów miednicy. Często guzom tym nie towarzyszą żadne objawy, a znajdywane są zupełnie przypadkowo podczas badań prowadzonych z innych wskazań. Celem pracy jest prezentacja przypadku, w którym w wyniku powstania mięśniaków macicy i odkładania się w nim związków wapnia doszło do powiększenia i stwardnienia narządu powodującego porażenie splotu krzyżowego. Pacjentka lat 57 zgłosiła się do poradni neurologicznej z powodu długotrwałych dolegliwości bólowych kręgosłupa w odcinku lędźwiowo-krzyżowym i bólem promieniującym do prawej kończyny dolnej. W wyniku przeprowadzonej diagnostyki obrazowej nie stwierdzono ewidentnych zmian strukturalnych w obrębie kręgosłupa, które mogłyby powodować zaburzenia funkcjonalne kończyn dolnych. Badanie TK uwidoczniło natomiast znacznych rozmiarów mięśniakowatą macicę. Powiększenie macicy w wyniku patologicznego rozrostu spowodowało zaburzenia stosunków anatomicznych w miednicy i ucisk jej na sąsiadujące z nią struktury, w tym splot krzyżowy. Interpretacja badań obrazowych mięśniaków nie stwarza problemów, jednak w przypadkach kiedy dochodzi do ich zwapnień, obraz zmienionego narządu znacznie odbiega od normy. Ma to istotne znaczenie zwłaszcza dla klinicystów, którzy powinni znać ich odmienny wygląd oraz możliwość interakcji zmienionego narządu z przylegającymi strukturami. KEY WORDS: pelvic calcification, uterine myoma, sacral plexus, computed tomography ABSTRACT Fibroids are one of the most common pelvic tumors in women. These tumors are often not accompanied by any symptoms and are found by chance during research for other indications. The aim of this work is to present the case in which the creation of uterine fibroids and deposition of calcium compounds in those led to an enlargement and callosity of the organ causing the sacral plexus paralysis. Patient, 57, was admitted to the neurological clinic because of long-term back pain in the lumbosacral segment and pain radiating to the right leg. As a result of diagnostic imaging, there were no obvious structural changes in the spine, which may have caused functional disorders of the lower limbs. A CT scan revealed significant size of fibroid uterus. Enlargement of the uterus as a result of abnormal growth caused disorders in the anatomy of pelvis and its pressure to neighboring structures, including sacral plexus. The interpretation of imaging studies of fibroids does not pose a problem, but in cases when it comes to their calcification, the image of the amended organ is far from the norm. This is important especially for clinicians who need to know their different appearance and the ability to interact with adjacent structures.

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

Lymphangiomatosis is an uncommon disease process characterized by multisystem lymphatic malformations that can involve numerous body systems, including organs, muscles, soft tissues, and bones. Involvement of the nervous system is rare and has even been previously described as a site of sparing. We present a case of a 24-year-old female with known lymphangiomatosis, presenting with acute onset of lower extremity paresthesias, weakness, and new urinary retention. MRI of the pelvis revealed lymphangiomatosis of the sacral plexus, which has not been previously reported. We will review the clinical and imaging manifestations of lymphangiomatosis and provide a differential diagnosis for masses of the lumbosacral plexus. Although lower extremity pain and weakness encountered in the emergency department or outpatient setting is most frequently caused by lumbar spine pathology, occasionally, abnormalities of the lumbosacral plexus may prove to be the cause. While peripheral nerve sheath tumors lead the differential diagnosis of tumor or tumor-like entities involving the lumbosacral plexus, lymphangiomatosis is a rare differential consideration. [ABSTRACT FROM AUTHOR]

Aim: Development of an examination protocol for investigation of functional integrity and microstructural damage of peripheral nerves (PN) at different locations using diffusion tensor imagi ng (DTI). Consequently, we want to implement this protocol into clinical practice. Subjects and methods: We investigated 15 healthy volunteers and 15 patients with a 3T MRI, scanner usi ng the DTI method. We attempted to visualize the brachial plexus, lumbosacral plexus and the course of PN in the limbs of healthy volunteers. In patients, we focused on the examination of damaged parts of the PN to display these pathologies. Results: We managed to obtain a valid visualization of the brachial plexus, lumbosacral plexus and the course of PN in the limbs us i ng DTI. Throughout the study, we encountered some limitations of this method, particularly motion artifacts which interfered with the quality of nerve structure imaging and problems in differentiating nerve fibers from muscle fibers. These technical problems could be reduced to a certain extent using adequate coils, optimizing imaging protocols and data processing methodology. Conclusion: Despite some technical limitations, this paper demonstrates the possibility of obtaini ng a valid display of PN in different locations us i ng the DTI method. DTI is an additional non-invasive imagi ng technique providi ng valuable information useful in the decision-maki ng diagnostic and therapeutic process for various PN pathologies. Technological advances and further improvements of MRI techniques in the future are likely to result in a wider use of this technique in clinical practice. [ABSTRACT FROM AUTHOR]

Ultrasound guidance currently represents the gold standard for regional anesthesia. In particular for lower extremity blocks, despite the heterogeneity and the lack of large randomized controlled trials, current literature shows a modest improvement in block onset and quality compared with other localization techniques. This review aims to present the most recent findings on the application of ultrasound guidance for each single lower extremity approach.

Introduction Due to the realistic colour, texture conservation and preservation of biomechanical properties, Thiel-embalming is becoming the main embalming procedure for clinical courses and research based on human cadaver material. The aim of this study is to establish a new procedure that allows advanced microdissection of small vessels and intraorganic nerves in Thiel-embalmed material. Material and methods/results After a classical gross anatomical dissection, human hemipelves underwent repetitive application of 3 consecutive steps: (i) maceration with alloy of nitric acid and MiliQ water 1:10 for 24–48 h. (ii) Immersion: the hemipelves were rinsed under tap water for 20–30 min. and placed in a water bath for 1 h. The nerves become more prominent due to the swelling and increased water content. (iii) microdissection under surgical microscope. To facilitate the organ visualization perfusion with polyurethane (Pu4ii, VasQtec ® , Switzerland) in red/blue for arteries/veins respectively has been performed. Conclusion By using the proposed procedure, we performed satisfactory microdissection on Thiel-embalmed samples. The combination with polyurethane vascular casting permits visualization of small arterioles and venules in a range of 20–25 μm. The method is very suitable for demonstration of somatic and vegetative nerves. Branches of the sacral plexuses and autonomic nerves from the superior and inferior hypogastric plexus have been tracked up to the smallest intraorganic branches in a range of 12.5–15 μm. In conclusion, the established combined procedure offers a new possibility for advanced microdissection, which will allow acquisition of clinically relevant information about organ specific micro- vascularization and innervation. [ABSTRACT FROM AUTHOR]