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PubMedDate not supplied

Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly.

BACKGROUND AND OBJECTIVES: This prospective randomized study was designed to determine the hemodynamic effects and quality of combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia in the elderly for repair of proximal femoral fractures. METHODS: Twenty-nine elderly patients ranging in age from 68 to 97 years were randomly assigned to 2 groups: a spinal anesthesia group with single-shot 3 mL 0.5% plain bupivacaine, and a combined block group with 30 mL lidocaine 1.33% with epinephrine for the posterior lumbar plexus block and 10 mL same mixture for the parasacral block and an iliac crest block with 5 mL lidocaine 1%. RESULTS: No need for general anesthesia was encountered in either group. Anesthesia was judged unsatisfactory in 1 of 15 patients in the combined block group. The initial decrease of mean arterial pressure was 38% in the spinal group and 27% in the block group and was not significantly different. A more prolonged hemodynamic effect was found in the spinal group, indicated by the more frequent use of ephedrine to stabilize blood pressure (P<.05). Patients over 85 years had a significantly larger decrease in blood pressure than younger patients (P<.01). CONCLUSIONS: Plain bupivacaine spinal anesthesia and combined lumbar/sacral plexus block provided adequate anesthesia for repair of hip fracture in the elderly. Hypotension was induced by both the combined peripheral nerve block and plain bupivacaine spinal anesthesia in aged patients; hypotension was found to be longer lasting after spinal anesthesia and of a larger magnitude in patients over 85 years of age.

Age Factors↗

PubMedDate not supplied

Continuous lumbar plexus block: Use of radiography to determine catheter tip location.

BACKGROUND AND OBJECTIVES: The purpose of this article is to document where a lumbar plexus catheter introduced by the posterior approach will track and to evaluate the benefit of using systematic radiographic verification of catheter placement. METHODS: A continuous lumbar plexus block (CLPB) by the posterior approach was performed on 169 consecutive adult patients scheduled for major hip, thigh, or knee surgery. Each catheter was verified by radiography using 10 mL contrast medium. The correct position of the catheter showed a caudally and laterally oriented contrast spindle. RESULTS: Epidural spread of the contrast medium occurred in 3 of 169 patients (1.8%). Only 1 patient had a clinically relevant epidural spread of local anesthetic. Successful block of the lumbar plexus was achieved in the other 166 cases. CONCLUSIONS: Epidural spread of local anesthetic during lumbar plexus block should be expected to be relatively common. It can be easily identified clinically with fractionated doses of local anesthetic. The catheter tip was identified in the epidural space by radiographic verification in only 1.8% of cases. This expensive procedure is therefore unnecessary except when an unusual location is suspected, but not necessary to confirm a catheter assumed to be correctly positioned.

Aged↗

PubMed1997

Continence mechanism of the isolated female urethra: an anatomical study of the intrapelvic somatic nerves.

PURPOSE: A neuroanatomical study was initiated to gain better insight into the continence mechanism of the isolated urethra in women. MATERIALS AND METHODS: We performed a detailed gross and histological neuroanatomical study to identify the intrapelvic somatic pathway from the sacral spinal cord to the female urethral sphincter. Gross anatomical dissection was performed in 5 formalin fixed female adult pelvises by tracing the autonomic nerves from the pelvic plexus and the spinal somatic nerves from S2-S4 to the urethral sphincter. Immunohistochemical staining of urethral step sections with a neuropeptide specific antibody was performed to demonstrate the course of the periurethral somatic nerves in relation to the vaginal wall. RESULTS: Our study demonstrated an intrapelvic somatic pathway derived from the S2, S3 and S4 sacral roots, distinct from the peripheral pudendal nerve, supplying the levator ani and the urethra. The somatic nerves travel beneath the endopelvic fascia in close relation to the inferior vascular pedicle of the bladder and are susceptible to injury during radical pelvic surgery. Mixed autonomic fibers from the pelvic plexus travel along the course of the ureter and are also intimately associated with the vascular pedicle of the bladder. Immunohistochemical staining of urethral step sections demonstrated that the periurethral nerves travel in close relation to the lateral and anterior vaginal wall. CONCLUSIONS: We believe that the identification of intrapelvic somatic pathways to the urethra provides a basis for developing surgical techniques to preserve urethral somatic innervation during radical pelvic surgery in women.

Adult↗

PubMed1992

[Multiple positional relationships of nerves arising from the sacral plexus to the piriformis muscle in humans].

The positional relationships between the piriformis muscle and the nerves which arise from the sacral nerve plexus were studied in 514 sides of 257 Japanese adults. These were classified into Types I-XIII and numerous subtypes based on: 1) the number of nerves perforating the piriformis muscle, 2) whether all or part of the nerve perforated the muscle, 3) the order of perforation and position in the muscle, and 4) communications between the nerves. In this paper, the multiple positional relations between the nerves and the piriformis muscle, the frequencies of the various types, and the order of priority concerning the perforation of nerves through the muscle are discussed. 1) The typical case, Type I, in which the piriformis muscle is not perforated by nerves except for a part of the superior gluteal nerve, was found in 309 (60%) of 514 sides. Types III-X, in which the muscle is perforated by additional nerves, were found in 195 sides (38%), and in 175 of these, all or part of the common peroneal nerve passed through the muscle. Types XI-XIII, in which the inferior gluteal nerve and other nerves pass above the piriformis muscle, were found in 10 sides (2%). Among all types, the following were generally seen: Type V, the piriformis muscle is perforated by both the inferior gluteal and common peroneal nerves; Type VII, the muscle is perforated by the two above-mentioned nerves and part of the posterior femoral cutaneous nerve (Fig. 16, Table 1). The common peroneal nerve followed two courses (a combination of over, through, and under the piriformis muscle) in 49 extremities. In the 4 cases of Type X (1%), the tibial nerve was divided into two components due to the intervention of the most caudal bundle of the piriformis or an unknown muscle. The dorsal component passed through the muscle, while the ventral component followed the typical course under the muscle (Figs. 9-11). Therefore, in the above-mentioned 53 cases as well as in other cases, the sacral nerve plexus cannot be divided into ventral and dorsal layers up to the sacral nerve roots, as in typical cases. Type II, in which the piriformis muscle is perforated by only a caudal branch of the superior gluteal nerve, was found in about 16% of 249 cases; this type was accompanied by some of the other types (Table 2). In the extraordinary case of Type XII with Type II, a branch of the superior gluteal nerve passed under the piriformis muscle (Fig. 13).(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗

PubMed2000

Sacral neural crest cells colonise aganglionic hindgut in vivo but fail to compensate for lack of enteric ganglia.

The vagal neural crest is the origin of majority of neurons and glia that constitute the enteric nervous system, the intrinsic innervation of the gut. We have recently confirmed that a second region of the neuraxis, the sacral neural crest, also contributes to the enteric neuronal and glial populations of both the myenteric and the submucosal plexuses in the chick, caudal to the level of the umbilicus. Results from this previous study showed that sacral neural crest-derived precursors colonised the gut in significant numbers only 4 days after vagal-derived cells had completed their migration along the entire length of the gut. This observation suggested that in order to migrate into the hindgut and differentiate into enteric neurons and glia, sacral neural crest cells may require an interaction with vagal-derived cells or with factors or signalling molecules released by them or their progeny. This interdependence may also explain the inability of sacral neural crest cells to compensate for the lack of ganglia in the terminal hindgut of Hirschsprung's disease in humans or aganglionic megacolon in animals. To investigate the possible interrelationship between sacral and vagal-derived neural crest cells within the hindgut, we mapped the contribution of various vagal neural crest regions to the gut and then ablated appropriate sections of chick vagal neural crest to interrupt the migration of enteric nervous system precursor cells and thus create an aganglionic hindgut model in vivo. In these same ablated animals, the sacral level neural axis was removed and replaced with the equivalent tissue from quail embryos, thus enabling us to document, using cell-specific antibodies, the migration and differentiation of sacral crest-derived cells. Results showed that the vagal neural crest contributed precursors to the enteric nervous system in a regionalised manner. When quail-chick grafts of the neural tube adjacent to somites 1-2 were performed, neural crest cells were found in enteric ganglia throughout the preumbilical gut. These cells were most numerous in the esophagus, sparse in the preumbilical intestine, and absent in the postumbilical gut. When similar grafts adjacent to somites 3-5 or 3-6 were carried out, crest cells were found within enteric ganglia along the entire gut, from the proximal esophagus to the distal colon. Vagal neural crest grafts adjacent to somites 6-7 showed that crest cells from this region were distributed along a caudal-rostral gradient, being most numerous in the hindgut, less so in the intestine, and absent in the proximal foregut. In order to generate aneural hindgut in vivo, it was necessary to ablate the vagal neural crest adjacent to somites 3-6, prior to the 13-somite stage of development. When such ablations were performed, the hindgut, and in some cases also the cecal region, lacked enteric ganglionated plexuses. Sacral neural crest grafting in these vagal neural crest ablated chicks showed that sacral cells migrated along normal, previously described hindgut pathways and formed isolated ganglia containing neurons and glia at the levels of the presumptive myenteric and submucosal plexuses. Comparison between vagal neural crest-ablated and nonablated control animals demonstrated that sacral-derived cells migrated into the gut and differentiated into neurons in higher numbers in the ablated animals than in controls. However, the increase in numbers of sacral neural crest-derived neurons within the hindgut did not appear to be sufficiently high to compensate for the lack of vagal-derived enteric plexuses, as ganglia containing sacral neural crest-derived neurons and glia were small and infrequent. Our findings suggest that the neuronal fate of a relatively fixed subpopulation of sacral neural crest cells may be predetermined as these cells neither require the presence of vagal-derived enteric precursors in order to colonise the hindgut, nor are capable of dramatically altering their proliferation or d

Animals↗

PubMed1995

Muscles of the pelvic outlet in the rhesus monkey (Macaca mulatta) with special reference to nerve supply.

BACKGROUND: The manner of innervation of the muscles of the inferior limb, pelvic outlet, and tail in rhesus monkey (Macaca mulatta) was investigated in detail in 11 pelvic halves of four males and two females. RESULTS: The origins of the pudendal nerve were widespread and overlapped the sacral plexus. After removal of the bone structures, detailed dissection revealed the origin of the pudendal nerve to ventrocaudally overlap the sacral plexus. This dorsoventral branching pattern between the sacral plexus and the pudendal nerve is similar to that in Urodela (Akita, 1992b), Lacertilia (Akita, 1992a) and Aves (Akita et al., 1992a), and is a basis for morphological understanding of the muscles of the pelvic outlet. CONCLUSIONS: The muscles of the pelvic outlet consist of the levator, sphincter, and tail muscle groups, based on the stratification of the supplying nerves the former two groups likely derive from the ventral muscles of the inferior limb, and the latter group from the ventral caudal (trunk) muscles.

Anatomy, Artistic↗

PubMed1999

The use of patient-controlled boluses of local anaesthetic via a psoas sheath catheter in the management of malignant pain.

Patients who develop malignant infiltration of the psoas muscle and the lumbar plexus often experience a severe complex pain syndrome characterised by deep somatic pain, neuropathic pain and psoas spasm. Conventional analgesic regimes may not relieve these symptoms adequately. We describe the use of patient-controlled boluses of local anaesthetic via a psoas sheath catheter in this scenario. The recent availability of portable infusion pumps with the capability to deliver large volume boluses with long lockout times made this intervention possible and allowed the patient to be discharged home with effective relief of pain.

Analgesia, Patient-Controlled↗

PubMed1991

Comparison of lumbar plexus block versus conventional opioid analgesia after total knee replacement.

A randomised controlled study was undertaken to assess the analgesic efficacy of continuous lumbar plexus block for the first 48 hours after total knee replacement surgery. Boluses of 0.5% bupivacaine with adrenaline 1 in 200,000 (0.3 ml/kg) were administered through a cannula inserted into the neurovascular sheath of the femoral nerve. Thirteen patients who received this block required significantly less morphine than a control group of 16 patients. Pain scores were similar and there were no complications related to this technique.

Adolescent↗

PubMed2003

An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery.

STUDY DESIGN: The distribution of the lumbar plexus was analyzed using cadavers. OBJECTIVE: To clarify the safety zone to prevent nerve injuries with respect to retroperitoneal endoscopic surgery. SUMMARY OF BACKGROUND DATA: Surgical approaches to the retroperitoneal space vary among surgeons. Recently, retroperitoneal endoscopic surgery has been applied to various spinal disorders. When the psoas major muscle is separated during retroperitoneal endoscopic surgery, there is a potential risk of injury to the lumbar plexus or nerve roots. However, there is sparse knowledge regarding the relationship between the greater psoas muscle and the lumbar plexus. METHODS: A total of 30 cadavers were analyzed. Six lumbar spines of the cadavers were cut in parallel with the lumbar disc space. Each axial section was photographed and captured into a computer. The distribution of the lumbar plexus was analyzed using computer images. The positions where the genitofemoral nerve emerged on the abdominal surface of the psoas major muscle were analyzed using 24 cadavers. RESULTS: L2/3 and above, all parts of the lumbar plexus, and nerve roots were located from the dorsal fourth of the vertebral body and dorsally. The genitofemoral nerve descends obliquely forward through the psoas major muscle, emerging on the abdominal surface between the cranial third of the L3 vertebra and the caudal third of the L4 vertebra. The safety zone of the psoas major muscle to prevent nerve injuries, excluding the genitofemoral nerve, is at L4/L5 and above. CONCLUSIONS: The safety zone, excluding the genitofemoral nerve, is at L4-L5 and above.

Cadaver↗

PubMed1992

[Truncal blocks of the lower limb].

Plexus nerve blocks of the lower limb have been described for many years but were seldom used until recently. Postoperative analgesia is one of the main indications of these blocks. The blockade of both lumbar and sciatic plexuses is required for most of the surgical procedures performed on the proximal part of the lower limb. Nerve stimulators account for less difficulties to perform such blocks and results are more reliable. Several pharmacokinetic studies have documented that toxic thresholds of plasma concentrations of local anaesthetics are not reached with the doses commonly injected. Many different techniques and landmarks have been described providing several alternatives to perform these blocks according to the type and the localisation of the surgical procedure. Extensive indications are reported for day case surgery or patients at risk.

Ankle↗

PubMed1981

[Crural and lumbar plexus neuropathies under anticoagulant treatment].

Thirteen cases of crural or, less often, lumbar plexus neuropathies are reported which were secondary to hematomas in patients under anticoagulant therapy. They are the most frequent peripheral neurological complications of anticoagulant therapy. The clinical symptoms, which often point directly to the diagnosis, are discussed and several additional investigations (conventional X-ray, transverse tomography, EMG, etc.) are presented. The criteria for prognosis and therapeutic problems, in particular the indication for surgical drainage of the hematoma or for neurolysis, are discussed. Finally, the pathogenic mechanisms of these neuropathies are outlined.

Abdomen, Acute↗

PubMed1999

Nerve injury associated with anesthesia: a closed claims analysis.

BACKGROUND: Nerve injury associated with anesthesia is a significant source of morbidity for patients and liability for anesthesiologists. To identify recurrent and emerging patterns of injury we analyzed the current American Society of Anesthesiologists (ASA) Closed Claims Project Database and performed an in-depth analysis of claims for nerve injury that were entered into the database since the authors' initial report of the subject. METHODS: The ASA Closed Claims Database is a standardized collection of case summaries derived from the closed claims files of professional liability insurance companies. Claims for nerve injury that were not included in the authors' 1990 report were reviewed in-depth. RESULTS: Six hundred seventy (16% of 4,183) claims were for anesthesia-related nerve injury. The most frequent sites of injury were the ulnar nerve (28%), brachial plexus (20%), lumbosacral nerve root (16%), and spinal cord (13%). Ulnar nerve (85%) injuries were more likely to have occurred in association with general anesthesia, whereas spinal cord (58%) and lumbosacral nerve root (92%) injuries were more likely to occur with regional techniques. Ulnar nerve injury occurred predominately in men (75%) and was also more apt to have a delayed onset of symptoms (62%) than other nerve injuries. Spinal cord injuries were the leading cause of claims for nerve injury that occurred in the 1990s. CONCLUSION: New strategies for prevention of nerve damage cannot be recommended at this time because the mechanism for most injuries, particularly those of the ulnar nerve, is not apparent.

Adolescent↗

PubMed1988

Continuous blockade of the lumbar plexus after knee surgery--postoperative analgesia and bupivacaine plasma concentrations. A controlled clinical trial.

In a double blind, randomised, controlled investigation the analgesic effect of a continuous block of the lumbar plexus with bupivacaine compared with sodium chloride was examined in 20 patients with postoperative pain after knee-joint surgery. The infusion was given through a catheter inserted in the neurovascular fascial sheath of the femoral nerve, according to the three-in-one block technique. The patients treated with bupivacaine had significantly lower pain scores and a significantly lower demand for morphine. Side effects related to the catheters or the infusions of bupivacaine were not observed.

Adolescent↗

PubMed1987

[Macroscopic study and structure of the nerve of the levator muscle of the anus].

Beginning at the sacral plexus the nerve disposition can be found to follow two modalities: first disposition in 2/3 of all cases having a cranial nerve branch for the elevator portion and a caudal nerve branch for the sphincter portion; second disposition in 1/3 of all cases having a branch divided in its terminal part into 2 ramus branches, one for the elevator portion and one for the sphincter portion. On the average the nerve contains 539 fibers of which 73% are myelinated and 27% non myelinated. The fibrillar content is identical for both branches of either disposition.

Anal Canal↗

PubMed2000

[Acute toxic accident following lumbar plexus block with bupivacaine].

We report the case of a patient who experienced ventricular dysrhythmias and seizure five minutes after the injection of 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine, during a lumbar plexus block performed via the posterior approach described by Winnie. The patient who underwent his total hip arthroplasty was still anaesthetised and under controlled ventilation at the time of bupivacaine administration. Aspiration test performed before injection was negative. Normal cardiac activity and stable haemodynamic condition were restored after one hour of resuscitation including 15 electric shocks and administration of epinephrine (40 mg) and clonidine (300 micrograms). The patient was discharged without neurologic sequelae after four days in the ICU.

Anesthesia, Spinal↗

PubMed2005

Lateral branches of dorsal sacral nerve plexus and the long posterior sacroiliac ligament.

Non-specific low back pain and peripartum pelvic pain have aetiologies that may feature the sacroiliac region. This region possesses many potential pain-generating structures sharing common sensory innervation which makes clinical differentiation of pathoanatomy difficult. This anatomical study explores the relationship between the long posterior sacroiliac ligament (LPSL) and the lateral branches of the dorsal sacral nerve plexus. Twenty-five sides of the pelvis from 16 cadavers were studied, three for histological analysis and 22 for gross anatomical dissection. We found that the LPSL is penetrated by the lateral branches of the dorsal sacral rami of predominantly S2 (96%, 21/22) and S3 (100%, 22/22), variably of S4 (59%, 13/22) and rarely of S1 (4%, 1/22). Some of the penetrating lateral branches give off nerve fibres that disappear within the ligament. These findings provide an anatomical basis for the notion that the LPSL is a potential pain generator in the posterior sacroiliac region.

Aged↗

PubMedDate not supplied

Anatomy of the pudendal nerve and its terminal branches: a cadaver study.

BACKGROUND: This study documents the anatomy of the pudendal nerve, which has a major role in maintaining faecal continence. Unexpected faecal incontinence can develop following perineal surgery even when the anal sphincters are not damaged. In addition, injury to the pudendal nerve might be encountered during pelvic procedures such as a sacrospinous colpopexy. METHODS: An anatomical study on 28 cadavers was conducted to examine the course of the pudendal nerve and its branches in the perineum. RESULTS: In five of the 28 cadavers dissected (four male, one female), a nerve plexus was found within the ischiorectal fossa in close proximity to the anal sphincters. The plexus received contributions from interconnecting branches of the inferior rectal and perineal nerves to innervate the external anal sphincter. In 11 of the 28 cadavers (five female, six male) an additional nerve arose from the medial aspect of the pudendal nerve at the level of the sacrotuberous and sacrospinous ligaments. This nerve continued distally and gave several branches to the perineum and the levator ani muscle. CONCLUSION: A sound knowledge of the anatomical variations of the pudendal nerve and its branches is essential for all surgeons operating in the perineal region.

Aged↗

PubMed1994

The rostrocaudal organization in the dorsal root ganglia of the rat: a consequence of plexus formation?

The dorsal root ganglia (DRGs) of the rat have a rostrocaudal organization. This organization can most easily be demonstrated in fetal and neonatal rats because the spatial relationships of their DRGs are maintained better in tissue sections than those of mature rats. This review is concerned with the way in which the rostrocaudal organization of the DRGs is generated. Wheat germ agglutinin--horseradish peroxidase/horseradish peroxidase labeling of peripheral nerves of the brachial and lumbar plexuses shows that the position of the somata of the sensory neurons of the labeled nerves can be restricted to rostral or caudal halves of DRGs. Labeling of the thoracic nerve or its branches always results in labeling throughout the entire thoracic DRG. After application of the marker to forelimb nerves, it was observed that whenever a DRG is labeled only partially, its spinal nerve is correspondingly labeled partially as well. These data suggest that the rostrocaudal organization in the DRG is related to the formation of the plexuses. During development nerve fibers can be segmentally labeled, using the subdivision of the DRGs into a rostral and a caudal half to keep together as they find their way through the plexus. Application of label to forelimb skin, hindlimb skin and even thoracic skin can result in labeling of rostral or caudal halves of a DRG. A possible explanation might be that each dermatome can be divided into a skin area innervated by the rostral half of a DRG and a skin area innervated by the caudal half of the same dorsal root ganglion. In the rat, the segmental sensory innervation of muscles during development has not yet been investigated. The question of whether the segmental unit of innervation of a muscle is a whole DRG or half a DRG therefore still remains unanswered.

Animals↗