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PubMed1998

Type II neurofibromatosis presenting as quadriceps atrophy.

A young woman aged 26 years presented with atrophy of the left quadriceps progressing over one year. Magnetic resonance imaging (MRI) showed a large lesion of the lumbar plexus compatible with neurinoma. Cerebral MRI revealed a lesion in the right eighth cranial nerve also compatible with neurinoma. On further questioning of the patient, it was learned that her mother had undergone surgery twice for acoustic neurinoma. Type II neurofibromatosis was diagnosed from the basis of clinical picture, neuroimaging findings and family history. This case is unusual for the lack of central nervous system (CNS) symptoms. Expansive radicular lesions compatible with neurinoma should prompt cerebral MRI. Regular examination of family members at risk and early diagnosis can decrease the high mortality associated with this condition.

Adult↗

PubMed1995

[An atraumatic needle for continuous epidural and plexus anesthesia].

The needle type introduced by Edward Tuphy for continuous spinal anaesthesia in 1944 is still used as the standard instrument for epidural anaesthesia up to the present day. Puncture of the dura and severance of the epidural catheter are the typical, though fare, complications of this procedure, giving rise to most of the actions brought for damage suffered during obstetric anaesthesia. The cerebral spinal fluid loss caused by thick needles can have serious consequences, including subdural and intracranial haematoma, cranial nerve pareses, labyrinthine hearing impairments and pneumocephalus. Special Sprotte needle for catheter introduction. In spinal anaesthesia and lumbar puncture the Sprotte needle has proven a very suitable instrument for the CSF loss syndrome and, to a large degree, post-spinal headaches. To adapt the atraumatic properties of this needle point for epidural anaesthesia the needle has been equipped with a plastic ramp to direct catheter insertion, and the opening geometry has been slightly modified for epidural application (see Fig. 1). The lateral catheter channel projects into the base of the needle point, which is thus shortened, and the edges of the needle opening are rounded so that the catheters cannot be severed. This needle bears the type designated "Special Sprotte needle" (EP no. 271715, USP no. 4842585). Needle diameter and application fields. The 1.1-mm (19.5 G) needle with 23-G catheter was introduced for epidural anaesthesia and continuous plexus anaesthesia at the Würzburg University Hospital and has proven itself in routine clinical practice. A 20-G version is being tested with a 25-G catheter for continuous spinal anaesthesia at several centers in USA, because finer spinal catheters are not permitted there by the FDA. For continuous spinal anaesthesia this needle has been available without the modified opening geometry since 1989 in sizes 22 G and 24 G and is wide by used in Europe. CSE technique with special and standard Sprotte needles. Spinal analgesia or anaesthesia) can be performed with the special needle and 123-mm-long 27 G or 29 G standard Sprotte needles before placement of the peridural catheter.

Anesthesia↗

PubMed1988

Neurophysiologic maps of the cutaneous innervation of the external genitalia of the ewe.

The area of skin supplied by the afferent fibers in a peripheral nerve is called the cutaneous area (CA) of that nerve. The CA responsive to movement of wool or hair in the genital regions were mapped in 17 ewes, with the identifications of the peripheral nerves and of the spinal nerves contributing to the pudendal plexus being checked at necropsy. Differences were found in the origins and extent of CA of the cutaneous branches from the sacral plexus. The CA of the caudal rectal nerves and of a nerve that passed caudally between the caudal vertebrae and the ventral sacrococcygeus muscle lay lateral to the anus and in the adjacent skin of the tail. The CA of the proximal cutaneous branch and of the distal cutaneous branch from the pudendal nerve (or plexus) overlapped craniocaudally (by approx one-half) the CA of the distal cutaneous branch extending ventrally and ending just caudal to the ipsilateral mammary gland. The deep perineal nerve innervated the skin immediately lateral to the anus and vulva. The dorsal nerve of the clitoris innervated hairs on the ipsilateral half of the vulva. Other fibers in the pudendal nerve were presumed to pass into the mammary branch of the nerve. They innervated the skin ventral to the vulva, the ipsilateral mammary gland, and (in some ewes) areas of the skin cranial to the mammary gland. The CA of the genitofemoral nerve included the ipsilateral teat and the inguinal fossa.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1991

MRI of lumbar and sacral plexus nerve sheath tumours.

Seven patients with peripheral nerve sheath tumours affecting the lumbo-sacral plexus were examined with MR imaging utilizing a 1.5T magnet and spin echo pulse sequences. The majority of tumours were homogeneous in signal intensity and isointense with adjacent muscle on T1 weighted images and showed markedly increased signal intensity on T2 weighted images with central areas of relatively low signal intensity. An attempt to obtain a pathological correlation with the areas of low signal on T2 weighted images was unsuccessful. The use of Gadolinium DTPA in one patient resulted in irregular enhancement of both a neurogenic sarcoma and smaller neurofibromas. The multiplanar imaging capabilities, high soft tissue contrast, non-invasiveness, lack of ionizing radiation and the characteristic appearance of neural tumours makes MR ideal for imaging these lesions.

Adult↗

PubMed2005

In with the new, out with the old? Comparison of two approaches for psoas compartment block.

We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia.

Aged↗

PubMed2005

[Combined paravertebral lumbar plexus and parasacral sciatic nerve block for reduction of hip fracture in four patients with severe heart failure].

We experienced four cases of anesthesia for hip fracture reduction in patients with severe heart failure, where anesthesia was attempted with combined paravertebral lumbar plexus and parasacral sciatic nerve block instead of spinal anesthesia. The anesthesia was successful without any sequelae. The patients' characteristics are as follows. Case 1: 97-year-old woman with severe heart failure and old myocardial infarction. Case 2: 91-year-old man with pacemaker, heart failure and heart valve disease. Case 3: 93-year-old woman with severe heart failure and multi-vessel coronary artery stenosis. Case 4: 83-year-old woman with congestive heart failure and heart valve disease. Paravertebral lumbar plexus block was performed with Touhy needle which was directed to lumbar transverse process, then re-directed caudally. Psoas compartment was felt with loss of resistance. Twelve ml of 0.25% bupivacaine was injected. Sciatic nerve block was performed with a needle which was inserted at the midpoint between the greater trochanter and the sacral hiatus without (case 1, 2) or with nerve stimulator (case 3, 4). Eight ml of 0.25% bupivacaine was injected. During the anesthesia, propofol was injected for light sedation. Although this combined nerve block is difficult to perform compared with spinal anesthesia, this could be applicable for hip fracture reduction anesthesia, especially in patients with severe heart failure.

Aged↗

PubMed2004

A review of sacral nerve stimulation for the treatment of faecal incontinence.

Sacral nerve stimulation is an emerging surgical technique that uses chronic low-level electrical stimulation, applied to the nerves of the sacral plexus, to produce a clinically beneficial physiological effect on the lower bowel, pelvic floor and anal canal. Faecal incontinence is common, maximal conservative therapy may improve some patients but many require surgery. Results are variable and often unsatisfactory and further options are limited, the traditional end-point being the formation of a colostomy. Sacral nerve stimulation appears to be an alternative treatment that is successful, has low morbidity, is maintained in the medium term and associated with an improved quality of life. The technique has the advantage of a minimally invasive test procedure with high predictive value and the surgery is minor. The underlying mechanism of action although predominately neurological in nature remains to be determined. Precise patient selection is currently unclear however, results are superior to other techniques.

Electric Stimulation Therapy↗

PubMedDate not supplied

A clinical comparison of psoas compartment and inguinal paravascular blocks combined with sciatic nerve block.

The extent of inguinal paravascular blockade and psoas compartment blockade with sciatic nerve block was evaluated in 60 patients. Volumes of 30 ml and 20 ml 0.35% bupivacaine with 1/200,000 epinephrine were injected for lumbar plexus and sciatic nerve block, respectively. Complete lumbar plexus blockade was achieved in 73% of the group who were treated with the psoas compartment technique and 43% of the group who were treated with the inguinal paravascular technique. Sensory blockade of the femoral, lateral femoral cutaneous and obturator nerves was obtained in 100%, 97% and 77% of the patients in the psoas compartment group, and 93%, 63% and 47% of the patients in the inguinal paravascular group, respectively. Sensory blockade of the lateral femoral cutaneous and obturator nerves was more rapid with psoas compartment block. The study suggests that the psoas compartment block is effective in blocking the femoral, lateral femoral cutaneous and obturator nerves, but the inguinal paravascular block is only effective in blocking the femoral nerve.

Adult↗

PubMed1989

Evaluation of "3 in 1" lumbar plexus block in patients having muscle biopsy.

Winnie and co-workers described a technique of blocking the lateral cutaneous nerve of thigh, femoral and obturator nerves using one injection of local anaesthetic into the fibrous sheath surrounding the femoral nerve. We studied 40 patients undergoing biopsy of vastus medialis for investigation of malignant hyperpyrexia, for onset, quality and recovery from this block. The patients were assigned in a random double-blind fashion to receive 0.6 ml kg-1 of one of two anaesthetic solutions: 1% lignocaine with 1 in 100,000 noradrenaline or 0.25% bupivacaine. Bupivacaine produced a similar onset time but longer duration of action compared with lignocaine. Median peak plasma concentrations of six patients in each group did not approach values associated with toxicity. This study demonstrated a 12.5% and 87.5% partial and complete femoral nerve block, respectively, and a 67.5% success rate for lateral cutaneous nerve of thigh using Winnie's technique. There was no clinical evidence of obturator nerve block.

Adult↗

PubMed1992

Pudendal nerve topography in the rat spinal cord projections studied with the axonal tracer wheat germ agglutinin conjugated-horseradish peroxidase.

The spinal cord termination of the sensory fibers of the rat pudendal nerve has been determined by using the transganglionic transport of horseradish peroxidase conjugated to wheat germ agglutinin. The gross anatomical examination of the pudendal plexus indicated the existence of dorsal and ventral branches in the sensory division of the pudendal nerve. Either branch or both were sectioned and exposed to a 1% solution of the enzyme. After an average survival period of 48 hours, the resulting reaction product was studied both at the level of the dorsal root ganglia and the spinal cord. Labeled dorsal root ganglion cells were observed between L1 and S4 (peak in S1 and L6). Evidence of transganglionic transport of the tracer was observed from L5 to S2. The ventral branch projected medially in the superficial dorsal horn, while the dorsal branch projected laterally. Our findings are consistent with a segregation of sensibilities for the ventral and dorsal branches that convey urogenital (ventral branch) and anal (dorsal branch) cutaneous sensations at the level of termination of primary afferents.

Anal Canal↗

PubMed1999

Transcranial magnetic stimulation compared with upper motor neuron signs in patients with amyotrophic lateral sclerosis.

If patients with amyotrophic lateral sclerosis (ALS) present without upper motor neuron signs (UMNS) they do not meet current ALS research criteria. To compare how sensitively degeneration of upper motor neurons is detected clinically and by transcranial magnetic stimulation, 35 patients with ALS were studied. Nineteen patients had definite UMNS, nine patients had probable UMNS, and seven patients had no UMNS. Cortex, cervical nerve roots, and lumbar plexus were stimulated with a magnetic stimulator. Compound muscle action potentials from abductor digiti minimi and from anterior tibial muscles were recorded with surface electrodes. Responses to transcranial magnetic stimulation were considered abnormal if central motor conduction time was above the 99% upper limits or if there was no response to cortical but to peripheral stimulation. In all patients with definite UMNS central motor conduction was abnormal. In patients with probable UMNS it was abnormal in 67%, and in patients without UMNS it was abnormal in 71%. Abnormality of central motor conduction was neither correlated with the duration nor with the severity of the disease. The high rate of abnormalities of central motor conduction found in patients with ALS but without definite UMNS suggests that, in these patients, the diagnosis of ALS can be made more reliably if transcranial magnetic stimulation studies are performed.

Action Potentials↗

PubMedDate not supplied

Central nervous system toxicity following the administration of levobupivacaine for lumbar plexus block: A report of two cases.

BACKGROUND AND OBJECTIVES: Central nervous system and cardiac toxicity following the administration of local anesthetics is a recognized complication of regional anesthesia. Levobupivacaine, the pure S(-) enantiomer of bupivacaine, was developed to improve the cardiac safety profile of bupivacaine. We describe 2 cases of grand mal seizures following accidental intravascular injection of levobupivacaine. CASE REPORT: Two patients presenting for elective orthopedic surgery of the lower limb underwent blockade of the lumbar plexus via the posterior approach. Immediately after the administration of levobupivacaine 0.5% with epinephrine 2.5 microgram/mL, the patients developed grand mal seizures, despite negative aspiration for blood and no clinical signs of intravenous epinephrine administration. The seizures were successfully treated with sodium thiopental in addition to succinylcholine in 1 patient. Neither patient developed signs of cardiovascular toxicity. Both patients were treated preoperatively with beta-adrenergic antagonist medications, which may have masked the cardiovascular signs of the unintentional intravascular administration of levobupivacaine with epinephrine. CONCLUSIONS: Although levobupivacaine may have a safer cardiac toxicity profile than racemic bupivacaine, if adequate amounts of levobupivacaine reach the circulation, it will result in convulsions. Plasma concentrations sufficient to result in central nervous system toxicity did not produce manifestations of cardiac toxicity in these 2 patients.

Aged↗

PubMed1988

Nerve sheath tumors of the sciatic nerve and sacral plexus.

Eight patients with sciatic nerve and sacral plexus nerve sheath tumors, seen at Louisiana State University Medical Center in Shreveport, are presented. These cases illustrate the broad spectrum of pathology and modes of presentation of patients with nerve sheath tumors in this region. Patients can be divided into 4 groups. Group I includes subgluteal and/or thigh lesions with a well-defined mass on CT. Group II patients have neuroforaminal enlargement (defined by CT) and usually have radicular leg pain. Patients in group III have intrapelvic tumors with extension into the thigh. They usually have a poorly defined mass on CT. Group IV includes patients that have an intrapelvic mass (usually well defined) with radicular leg pain and/or mass effect. CT scanning proved to be the diagnostic procedure of choice. It delineated the location and extent of the tumor and thus was important in determining resectability. The variable course of these tumors is emphasized. A conservative nonoperative approach should be considered in asymptomatic and/or neurologically stable patients.

Adult↗

PubMed1995

Paravascular lumbar plexus block: block extension after femoral nerve stimulation and injection of 20 vs. 40 ml mepivacaine 10 mg/ml.

The goal of this prospective randomized study was to assess the extension of the "three-in-one" paravascular lumbar plexus block after femoral nerve stimulation and injection of 20 vs. 40 ml mepivacaine 10 mg/ml. Three-in-one blocks were achieved in 12 of 39 (31%) patients given 20 ml of 1% mepivacine (group 1), and 17 of 41 (41%) patients given 40 ml (Group 2) of the same solution (n.s.). The level of successful blockade at each nerve did not differ between groups. The femoral nerve was blocked in 92% vs. 93% of patients in groups 1 and 2, respectively; the obturator nerve in 62% vs. 78%; and the lateral cutaneous femoral nerve in 41% vs. 44%. We conclude that femoral nerve stimulation is effective in faciliating blockade in the femoral nerve but not the obturator or lateral cutaneous femoral nerve with the tested solution and volumes, and therefore not particularly effective for achieving complete 3-in-1 blockade. Within the clinically relevant range of 20-40 ml, the volume of mepivacaine 10 mg/ml does not appear to influence the extent of blockade.

Adult↗

PubMed1996

[Three-in-one block or femoral nerve block. What should be done and how?].

The "3 in 1" block and the femoral nerve block are widely used for lower limb surgery and postoperative analgesia. Whether these blocks are in fact a same regional block with two different names or represent definitively two different blocks remains controversial. A large number of anatomical as well as functional variations of the lumbar plexus have been described and complicate a rational analysis of the spread of local anaesthetics following these blocks. Anatomical, radiological and especially clinical data seem to confirm that these blocks are to be distinguished from one another. Femoral nerve block requires the use of a nerve stimulator and has a high success rate in the territory of the femoral nerve; a spread towards other lumbar nerves, especially the lateral femoral cutaneous nerve, is sometimes observed. The "3 in 1" block is supported by the idea of diffusion within a space that is located after going through two fascial layers. Even in experienced hands, the success predictive value is not high. However, once the "3 in 1" block is well performed, a complete anaesthesia covering the territories of the femoral nerve, the lateral femoral cutaneous nerve, and the obturator nerve occurs. Specific indications of each technique are different: major knee surgery and postoperative analgesia for the "3-in-1" block and leg surgery for femoral nerve block. The best approach for knee arthroscopy remains open for discussion.

Arthroscopy↗

PubMed1994

Posterior approach to the lumbar plexus combined with a sciatic nerve block using lidocaine.

A combination of lumbar plexus block, by a posterior technique, and sciatic nerve block can be a useful technique for outpatient anaesthesia. The purpose of this study was to examine the clinical characteristics of these blocks using lidocaine and to measure the serum lidocaine concentrations. Forty-five patients, undergoing lower extremity surgery, were studied. Sciatic nerve and lumbar plexus blocks were made with lidocaine, 680 mg with adrenaline 0.3 mg. For each patient the following data were collected: weight, age, sex, site of surgery, time to perform each block, needle depth, speed of onset of the sensory and motor blocks in the territories of the sciatic, femoral, obturator and lateral cutaneous (sensory) nerves and postoperative analgesic requirements. Lidocaine serum concentrations were measured in ten of these patients at 0, 2, 5, 10, 30, 60, 90 and 120 min after the second block. Analgesia was complete in 88% (40/45) of the patients. The remaining five patients needed analgesics (fentanyl 150 micrograms or less). Despite the high dose of lidocaine, the serum concentrations were within safe limits (mean +/- SD) (CMAX = 3.66 +/- 2.21 micrograms.ml-1). Only one patient had a serum concentration > 5 micrograms.ml-1 (CMAX = 9.54 micrograms.ml-1). This was associated with a contra-lateral extension of the block. We conclude that this combination of blocks is a valuable alternative for unilateral lower extremity anaesthesia. However, clinicians must be aware of the implications of a contra-lateral extension of the block.

Adolescent↗

PubMed1988

Clinical significance of sacral and pudendal nerve anatomy.

The neuroanatomy and neurophysiology of the external urethral closure mechanisms still are under debate because the motor fibers that emanate from the sacral plexus and pudendal nerve to supply this segment have not been traced, nor has their functional interrelationship been established. Therefore, we dissected 3 male human cadavers (aged 31 to 69 years) by tracing the entire sacral plexus, particularly the pudendal nerve, from the cauda equina throughout the branching of the nerves to their final destination. The dissection demonstrated that the extrinsic urethral sphincter, formed by the rhabdosphincter around the membranous urethra as well as the levator ani muscle and pelvic floor (especially the transversus perinei muscle), is innervated by somatic nerve fibers that emanate primarily from sacral roots S2 and S3. In 5 patients with neurogenic lower urinary tract dysfunction electrostimulation of the sacral root and pudendal nerve markedly increased intraurethral closure pressures. Stimulation of the pudendal nerve or its transversus perinei branch alone resulted in an increase in intraurethral closure pressure to 60 to 70 cm. water--an increase similar to that produced by stimulation of the sacral root without neurotomy. By means of neurotomy and/or neural blockade with lidocaine we were able to differentiate between the contributions of each muscular element to the external sphincteric mechanism. Almost 70 per cent of the closure pressure of the external urethral sphincter is induced by stimulation of the S3 ventral root, while the other 30 per cent derives from S2 and S4 neuronal impulses.

Adult↗

PubMed1994

[Perforation of dorsal branches of the sacral nerve plexus through the piriformis muscle and its relation to changes of segmental arrangements of the vertebral column and others].

To determine whether perforation of the dorsal branches arising from the sacral nerve plexus through the piriformis muscle is dependent on segmental migration of the vertebral column and others, the relationships between the perforating nerves (Fig. 1) and changes in the segmental composition of the following items were studied morphologically and statistically in 224 Japanese adults. Each of items 1) to 8) was classified in some mode or type depending on its composition and appearance. 1) Based on the length of the 8th rib and costal cartilage and whether or not the 8th to 10th ribs attached to the costal arch, the forms of the arch were classified into 6 types (Fig. 2-1). Type E, quoted commonly in many textbooks, in which the 8th to 10th ribs are all joined to the arch, was found in only 8 (6%) of 126 sides. A true 8th rib was found in 2 (3%), and a floating 10th rib was found in 59 (95%) of 62 sides. 2) The length of the 12th rib and costal cartilage, measured by a wet thread put on its inner surface, was classified into 4 types (Fig. 3-1): lacking (in this condition, the lumbar costal process appeared in 9 (2%) of 380 sides), short, normal (the length ranged from 5.1 cm to 13.4 cm) and long. Length varied from about 3 cm to 18.2 cm, with most cases concentrated in a range of 8 cm-14 cm. 3) Based on the number of presacral vertebrae, the vertebral column was classified as short (prefixed), normal, normal in number but abnormal in composition, and long (postfixed) (Table 4-1). The true "normal" type of 12 thoracic and 5 lumbar vertebrae was found in 196 (88%) of 224 bodies. Eleven thoracic and 5 lumbar, 13 thoracic and 4 lumbar, and 13 thoracic and 5 lumbar vertebrae were found in one body each, and thoracolumbar and lumbosacral vertebrae in 2 and 5 bodies, respectively. The long type of vertebral column appeared about twice as often as the short type. 4) Based on the height and appearance of the sacral promontory in the median plane, it was divided into 7 types (Fig. 5-1). The normal type, in which the promontory lay on the tip of the first sacral (25th) vertebra and projected sharply into the pelvic cavity, was found in 158 (71%) of 224 bodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Humans↗