Systematic review of sacral nerve stimulation for faecal incontinence and constipation (Br J Surg 2004; 91: 1559-1569).
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Constipation↗
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Effect of sacral neuromodulation on the rectum.
BACKGROUND: Sacral neuromodulation (SNM) is a new treatment for faecal incontinence. At present the exact underlying mechanism is still unclear. Modulation of the sacral reflex arcs might have an effect on rectal sensitivity, wall tension and compliance. METHODS: Fifteen consecutive patients with faecal incontinence who qualified for SNM underwent barostat measurements before and during neuromodulation. An 'infinitely' compliant plastic bag with a volume of 600 ml was placed in the rectum and connected to a computer-controlled barostat system. An isobaric phasic distension protocol was used. Patients were asked to report rectal filling sensations: first sensation (FS), earliest urge to defaecate (EUD) and an irresistible, painful urge to defaecate (maximum tolerated volume; MTV). Rectal wall tension and compliance were calculated. RESULTS: During isobaric phasic distension each patient experienced all rectal filling sensations at the time of stimulation. Median volume thresholds decreased significantly during stimulation, from 98.1 to 44.2 ml for FS (P = 0.003), from 132.3 to 82.8 ml for EUD (P = 0.001) and from 205.8 to 162.8 ml for MTV (P = 0.002). Pressure thresholds tended to be lower for all filling sensations, but only that to evoke MTV was reduced significantly by stimulation (37.3 versus 30.3 mmHg; P = 0.005). Median rectal wall tension for all filling sensations decreased significantly with stimulation. There was no significant difference between compliance before and during stimulation. CONCLUSION: SNM affects rectal sensory perception, but further research is required to clarify the mechanism.
Adult↗
Sacral nerve stimulation reduces corticoanal excitability in patients with faecal incontinence.
BACKGROUND: Sacral nerve stimulation (SNS) can produce symptomatic relief in patients with faecal incontinence. Moreover, peripheral nerve stimulation has been shown to affect brain function. The aim of this study was to determine whether SNS might produce important changes in cortical activity linked to improved continence. METHODS: In an experimental study, ten women with intractable faecal incontinence (mean age 51.3 years) were serially mapped with transcranial magnetic stimulation before and immediately after 14 days of temporary SNS (15 Hz, pulse width 210 micros), and then 2 weeks later. Anal sphincter electromyographic responses were recorded to cortical stimulation of multiple points over a scalp grid covering the bilateral medial cortex. Continence scores, anorectal manometry and rectal sensitivity data were also collected. RESULTS: SNS improved global symptom scores in the majority of patients; mean(s.e.m.) continence scores fell from 16.9(1.6) to 10.6(1.8) (P = 0.042). Cortical mapping showed a consistent decrease in corticoanal representation and overall excitability immediately after SNS compared with baseline (mean(s.e.m.) 38,083(13,669) versus 42,507(13,297) microV s; P = 0.017), which was reversed 2 weeks after SNS wire removal. CONCLUSION: SNS produces symptom benefit in patients with faecal incontinence that is associated with a reversible reduction in corticoanal excitability. SNS therefore drives dynamic brain changes that may play a functional role in influencing anal continence.
Adult↗
Outcome and cost analysis of sacral nerve stimulation for faecal incontinence.
BACKGROUND: Sacral nerve stimulation (SNS) may be successful in treating incapacitating faecal incontinence. The technique is expensive, and no cost analysis is currently available. The aim of this study was to assess clinical outcome and analyse cost-effectiveness. METHODS: Thirty-six consecutive patients underwent a two-stage SNS procedure. Outcome parameters and real costs were assessed prospectively. RESULTS: SNS was tested successfully in 33 of 36 patients, and 31 patients were stimulated permanently. In the first stage, eight of 36 patients reported minor complications (pain, infection or electrode dislocation), resulting in a cost of euro 4053 (range euro 2838-7273) per patient. For the second stage (permanent stimulation), eight of 33 patients had an infection, pain or loss of effectiveness, resulting in a cost of euro 11,292 (range euro 7406-20,274) per patient. Estimated costs for further follow-up were euro 997 per year. The 5-year cumulative cost for SNS was euro 22,150 per patient, compared with euro 33,996 for colostomy, euro 31,590 for dynamic graciloplasty and euro 3234 for conservative treatment. CONCLUSION: SNS is a highly cost-effective treatment for faecal incontinence. Options for further reduction of SNS costs include strict patient selection, treatment in an outpatient setting and using cheaper devices.
Adolescent↗
Variations in the number and position of human lumbar sympathetic ganglia and rami communicantes.
The purpose of this study is to provide precise anatomical and statistical information about the number and location of lumbar sympathetic ganglia and the number and length of the related rami communicantes, and to consider the neurological pathway for nociception from the low back. Three-hundred ninety-three ganglia and 719 rami communicantes from 50 human cadavers were identified by gross dissection. The number of ganglia in a single lumbar chain ranged from 2 to 6, the mean being 3.9. The mean lengths of rami connected to the 1st and 5th lumbar spinal nerves, respectively, were significantly longer and shorter than those connected to the 2nd, 3rd, and 4th nerves. The lumbar sympathetic ganglia and rami communicantes were not distributed segmentally. The present results may assist in understanding the nociceptive pathway from the low back.
Aged↗
The psoas quartus muscle.
We report an unusual finding in an adult male cadaver. During the routine dissection of the posterior abdominal wall as part of an anatomy course at our institution, an anomalous muscle was noted. This muscle originated from the transverse process of the left L3 vertebrae and the medial aspect of the quadratus lumborum. We believe this muscle to represent a variety of the psoas quartus that, to our knowledge, has only been described once before in the extant medical literature. The presence of a psoas quartus muscle may contribute to femoral nerve compression. The clinician may wish to consider this rare muscular anomaly in patients with symptoms of femoral nerve compression in which no other clear etiology is found. Furthermore, clinicians who image the posterior abdominal wall should be aware of this potential anomaly when interpreting the anatomy of this region.
Aged↗
Surgical anatomy of the pudendal nerve and its clinical implications.
A study of the surgical anatomy of the pudendal nerve (PN) was performed in 13 female and 7 male cadavers. The knowledge of the precise anatomy and anomalies of this important nerve would help in better localization of the nerve and its roots and branches for neurostimulation or for pudendal canal decompression in pudendal canal syndrome. Two routes were used in the dissection: gluteal and perineal. The PN was identified and its course was followed from its roots to its termination. The PN was composed of three roots derived from the 2nd, 3rd, and 4th anterior sacral rami (S 2,3,4). The roots received a contribution from S 1 in five cadavers and from S 5 in one. The three roots formed two cords. The first root continued as the upper cord while the second and third root fused together producing the lower cord. The PN was formed by union of the two cords a short distance proximal to the sacrospinous ligament, and then crossed the back of the ligament. In no specimen did the nerve cross the ischial spine. The inferior rectal nerve arose from the PN in the pudendal canal in 18 cadavers. In two cases it came out proximal to the canal; this would spare the two subjects the anorectal manifestations of the pudendal canal syndrome. As the PN crossed the back of the sacrospinous ligament, it gave origin to a branch that supplied the levator ani muscle. This branch was only found in male cadavers and we call it "accessory rectal nerve"; the levator ani muscle in such cadavers was doubly innervated on its perineal aspect.
Adult↗
Quantitative analysis of the dendrites of sacral preganglionic neurons in the cat.
Quantitative analyses were performed on the dendrites and somata of 25 electrophysiologically identified preganglionic neurons (PGN) obtained from the sacral spinal cord of the cat by intracellular injection of Neurobiotin or horseradish peroxidase. Total dendritic length and surface area were measured for each dendrite. The sizes of the stem dendrites measured at their base were positively correlated with the sizes of the entire tree and numbers of end branches. Total surface area of somata and dendrites averaged 39,138 microm(2); 90.7% of that was from the dendrites. To obtain measurements of the relative contributions of PGN dendrites to specific regions of the spinal cord, the percentage of each dendrite occupying eight spinal cord regions was recorded. Sixty-three percent of the dendrites projected dorsal to their somata, whereas an average of 33.3% of dendrites were located in the white matter, most of them in the lateral and dorsolateral funiculi. The neurons within this sample formed a continuum with some neurons having a large percentage of dendrites in lamina I but little in the white matter, whereas at the other end of the continuum were cells with the reverse configuration. The intermediate neurons had dendrites in both locations. Taken together, these data indicate a heterogeneous population of PGN in the lateral band of the sacral parasympathetic nucleus.
Animals↗
Aspects of the segmental innervation of the cat's hind limb.
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Animals↗
Reduction of the naturally occurring motor neuron loss by enlargement of the periphery.
Motor hyperplasia following the enlargement of the periphery by implantation of a supernumerary leg is not due to "remote control" of proliferation, as shown by motor neuron counts in 6-day chick embryos. We have tested the alternative hypothesis that we are dealing with reduction of the naturally occurring cell death. In normal development, the lumbar lateral motor column (l.m.c.) undergoes motor neuron degeneration resulting in a cell loss of at least 40%, which occurs between six and one-half and nine and one-half days. Following transplantation of supernumerary legs, cases selected for vigorous motility showed a numerical difference between experimental and contralateral (control) sides amounting to +11.0% to +27.5%. The transplants were innervated by varying combinations of thoracic and rostral lumbar nerves. We interpret our data in terms of survival of motor neurons which normally would have failed in a competition at the periphery but which were sustained by the enlarged peripheral fields. Our data do not permit a decision between the two alternatives: competition for synaptic sites or for a trophic agent. The surviving motor neurons are not limited to the rostral segments of the motor column but in most instances distributed along its entire rostro-caudal extent, implying a redistribution of all l.m.c. axons. The term "hyperplasia" is no longer appropriate for the phenomenon under consideration and should be replaced by the term "hypothanasia.""
Animals↗
Central distribution of efferent and afferent components of the pudendal nerve in macaque monkeys.
Central distribution of efferent and afferent components of the pudendal nerve was studied by the horseradish peroxidase (HRP) method in 13 macaque monkeys, i.e., in nine Japanese monkeys (Macaca fuscata), two rhesus monkeys (Macaca mulatta), and two crab-eating monkeys (Macaca fascicularis). The enzyme was applied to the central cut end of the pudendal nerve; then the monkeys were allowed to survive for 36 to 72 hr. Retrogradely labeled neuronal cell bodies of pudendal motoneurons constituted a slender longitudinal cell column in the ventral horn. The cell column extended from high or middle S1 to high or middle S2 in eight monkeys, from middle or low L7 to high S2 in four monkeys, and from high L7 to middle S1 in a monkey. The cell column appeared to correspond to Onuf's X nucleus in man. No sex difference was recognized in the position of the cell column. The average number of HRP-labeled pudendal motoneurons was larger in male than in female adult Japanese monkeys, whereas no sex difference was found in the average soma diameter of the pudendal motoneurons. Transganglionically labeled axons entered into the spinal cord through the S1 and S2 dorsal roots in 12 monkeys and through the L7 and S1 dorsal roots in one monkey. Labeled axons were distributed ipsilaterally in laminae I-VI and X of the spinal cord at the same and adjacent levels of entry of HRP-labeled dorsal root fibers (from L7 to S3 in 12 monkeys and from L6 to S3 in one monkey).(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
The organization of the pudendal nerve in the male and female rat.
Mature male and female Sprague-Dawley rats were used in this study to compare the organization of the pudendal nerve in the two sexes. Experiments included incubating the cut pudendal nerve in diamidino-2-phenylindole HCl (DAPI), fast blue (FB), or horseradish peroxidase (HRP) and injecting individual perineal muscles with these substances. In both sexes, incubation of the pudendal nerve labelled two motoneuron nuclei in the L5-L6 segments of the spinal cord. These nuclei are the dorsomedial (DM) and dorsolateral (DL) cell columns described by Schrøder (J. Comp. Neurol. 192:567-587, 1980). In agreement with previous studies, there were significantly more neurons in both nuclei in the male than in the female and the neurons were larger in the male. In both sexes, the DL and DM nuclei were characterized by a longitudinal dendritic structure. The DM nucleus also had numerous dendritic bundles extending across the midline, linking the DM nuclei bilaterally. Pudendal nerve afferent neurons were located in the L6 and S1 dorsal root ganglia. In the male, the afferent neurons were larger and more numerous. In both sexes, labelled pudendal afferent fibers in the spinal cord were located in the dorsal columns, the medial half of Lissauer's tract, the extreme medial edge of the dorsal horn, both ipsilaterally and contralaterally, and in a large terminal field in the dorsal gray commissure. No labelled afferents were seen in the intermediate or ventral gray. Perineal muscle injections established that there was no difference between males and females in the number of motoneurons innervating the external anal or urethral sphincters. In the female, urethral sphincter motoneurons accounted for almost all the DL motoneurons, and anal sphincter motoneurons accounted for almost all the DM motoneurons. The ischiocavernosus and bulbospongiosus muscles are vestigial in the female rat. In the male, neurons innervating the anal sphincter and bulbospongiosus muscles were intermingled in the DM nucleus. In contrast, in the DL nucleus, the urethral sphincter neurons were located in the lateral portion of the nucleus and the ischiocavernosus neurons were located in the medial portion.
Afferent Pathways↗
Bidirectional inhibitory interactions between the embryonic chicken metanephros and lumbosacral nerves in vitro.
During chicken embryonic development the metanephros forms from the uretic duct at embryonic day (E) 7. As the metanephric tissue develops between E7 and E10, it comes into close apposition with lumbosacral nerves. Coculturing of metanephric and nerve explants demonstrated that the Schwann cells of the sciatic nerve inhibit the migration of metanephric cells in a contact-dependent manner. Conversely, metanephric cells inhibit dorsal root ganglion axon extension in a contact-dependent manner. However, metanephric cells are not inhibited by contact with growth cones or axons. Dorsal root ganglion growth cones become sensitive to the inhibitory signals on the surfaces of metanephric cells around E8, a time when the metanephros is expanding into the territory occupied by nerves in vivo. These observations demonstrate inhibitory bidirectional tissue-tissue interactions in vitro and provide a novel model system for the study of contact-based guidance of both neuronal and non-neuronal cell migration.
Actins↗
Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: new insights into pathophysiology and treatment.
Diabetic lumbosacral radiculoplexus neuropathy (DLRPN) (also called diabetic amyotrophy) is a well-recognized subacute, painful, asymmetric lower-limb neuropathy that is associated with weight loss and type II diabetes mellitus. Nondiabetic lumbosacral radiculoplexus neuropathy (LRPN) has received less attention. Comparison of large cohorts with DLRPN and LRPN demonstrated that age at onset, course, type and distribution of symptoms and impairments, laboratory findings, and outcomes are similar. Both conditions are lumbosacral radiculoplexus neuropathies that are associated with weight loss and begin focally with pain but that evolve into widespread, bilateral paralytic disorders. Although both are monophasic illnesses, patients have prolonged morbidity from pain and weakness, and many patients become wheelchair-dependent. Although motor-predominant, there is unequivocal evidence that autonomic and sensory nerves are also involved. Cutaneous nerves from patients with DLRPN and LRPN show pathological evidence of ischemic injury (multifocal fiber loss, perineurial thickening and degeneration, neovascularization, microfasciculation, and swollen axons with accumulated organelles) and microvasculitis (mural and perivascular inflammation, separation and fragmentation of mural smooth muscle layers of microvessels and hemosiderin-laden macrophages). Controlled trials with immune-modulating therapies in DLRPN are in progress, and preliminary data suggest that such therapy may be beneficial in LRPN. It is likely that DLRPN and LRPN are immune-mediated neuropathies that should be separated from chronic inflammatory demyelinating polyneuropathy and from systemic necrotizing vasculitis.
Diabetes Mellitus, Type 2↗
Intrapartum maternal lumbosacral plexopathy.
There are many conflicting theories regarding the mechanism and prognosis of acute foot drop during labor. We report seven women who had arrested labor and foot drop. Six had short stature and one had a large newborn. All had weakness of ankle dorsiflexion, eversion, and inversion, and sensory loss in the L-5 dermatome. Superficial peroneal sensory nerve action potentials (SNAPs) were small or absent in six patients, and the sural SNAP was attenuated in one. Peroneal compound muscle action potential (CMAP) amplitude (recording from extensor digitorum brevis) was low in five, whereas the tibial CMAP was normal in all patients. Peroneal CMAP amplitude (recording from the tibialis anterior) was normal in three and small in three. Needle electromyography revealed decreased recruitment and fibrillation potentials in L-5-innervated muscles, mostly below the knee. We conclude that intrapartum foot drop occurs mostly in short women and is caused by lumbosacral trunk compression by the fetal head at the pelvic brim. The primary pathology is predominantly demyelination and recovery is complete in up to 5 months.
Adult↗
Evoked potentials elicited by stimulation of the lateral and anterior femoral cutaneous nerves in meralgia paresthetica.
Seventy-five consecutive patients with clinical symptoms and signs of meralgia paresthetica underwent bilateral somatosensory evoked potential (SEP) studies involving stimulation of skin areas innervated by the lateral and anterior femoral cutaneous nerves of the thighs. The most common abnormality was an absolute lateral femoral cutaneous SEP latency > 40 ms in 35 patients (47%), followed by an absent response in 14 patients (19%), an absolute latency < 40 ms but amplitude reduction > 50% compared with the contralateral response in 8 patients (11%), and an absolute latency < 40 ms but > 5 ms interside latency difference in 5 patients (7%). Anterior femoral cutaneous SEPs were of value in distinguishing meralgia paresthetica from a proximal lumbar radiculopathy in an additional 4 patients and confirming bilateral meralgia paresthetica in 10 patients.
Adult↗
Impaired glucose tolerance in nondiabetic lumbosacral radiculoplexus neuropathy.
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Aged↗
Meralgia paresthetica after strenuous exercise.
We present three patients with signs and symptoms of meralgia paresthetica (MP) after long-distance walking and cycling. No other possible causes of MP, such as trauma or exogenous compression, were present. A neuropathy of the lateral femoral cutaneous nerve was confirmed in all patients with somatosensory evoked potentials. We propose that conduction block due to local ischemia during repetitive muscle stretching was the probable cause for the neuropathy.
Adult↗