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PubMed2004

Minimizing the risk of neurologic injury in gynecologic surgery.

OBJECTIVE: The association of intraoperative neurologic injuries with gynecologic surgical procedures is well established. The sequelae of such injuries are usually transient and resolve with minimal intervention, although long-term disability can and does occasionally occur. The purpose of this study was to examine the mechanisms by which these injuries occur in order to reduce the risk of their occurrence. DATA SOURCES: A MEDLINE search was performed cross-referencing the index terms "neurological injury" and "gynecological surgery," from January 1, 1960 to December 31, 2002. METHODS OF STUDY SELECTION: This article, based on the data and results (Level I-III) obtained from the MEDLINE search, examined the most common neurologic injuries that occur in association with abdominal and vaginal surgical procedures routinely performed by gynecologists. TABULATION, INTEGRATION, AND RESULTS: Neurologic injuries after pelvic surgery all generally share a common etiology, specifically injury to one or more components of the lumbosacral nerve plexus. Three major factors that predispose to neurologic injury at the time of gynecological surgery are 1) the improper placement or positioning of self-retaining or fixed retractors, particularly those with deep lateral retractor blades; 2) improper positioning of patients in lithotomy position preoperatively; and 3) radical surgical dissection resulting in autonomic nerve disruption. Level I data strongly implicate the improper placement of self-retaining or fixed retractors as the most common cause of femoral nerve injury arising in association with abdominal surgical procedures. CONCLUSION: A thorough understanding of the anatomy of the lumbosacral nerve plexus and the mechanisms by which operative injuries to this plexus occur will enable the gynecologic surgeon to reduce the subsequent risk of their occurrence in his or her own surgical practice.

Female↗
PubMed1990

Nerves and nerve plexuses of the human vertebral column.

The origin, distribution, and termination pattern of nerves supplying the vertebral column and its associated structures have been studied in the human fetus by means of an acetylcholinesterase whole-mount method. The vertebral column is surrounded by ventral and dorsal nerve plexuses which are interconnected. The ventral nerve plexus consists of the nerve plexus associated with the anterior longitudinal ligament. This longitudinally oriented nerve plexus has a bilateral supply from many small branches of the sympathetic trunk, rami communicantes, and perivascular nerve plexuses of segmental arteries. In the thoracic region, the ventral nerve plexus also is connected to the nerve plexuses of costovertebral joints. The dorsal nerve plexus is made up of the nerve plexus associated with the posterior longitudinal ligament. This nerve plexus is more irregular and receives contributions only from the sinu-vertebral nerves. The sinu-vertebral nerves originate from the rami communicantes and, in the cervical region, also from the nerve plexus of the vertebral artery. Thick and thin sinu-vertebral nerves are found. Most frequently three types of thick sinu-vertebral nerves are observed, i.e., ascending, descending, or dichotomizing ones. Finally, the distribution of the branches of the ventral and dorsal nerve plexuses and of the sinu-vertebral nerves is described.

Cervical Plexus↗