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At least 811 records · Page 45Linked to original sources
PubMed2001

Short-term effects of sacral nerve stimulation for idiopathic slow transit constipation.

This study assessed the short-term clinical and physiological effect of continuous sacral nerve stimulation in patients with slow transit constipation. Some patients with idiopathic slow transit constipation are unresponsive to conservative treatments, while colectomy has a variable and poorly predictable outcome. Sacral nerve stimulation is a less invasive and reversible procedure that enables direct neuromodulation of the pelvic floor and hindgut. It has been used successfully in the treatment of urologic disorders and fecal incontinence, and some of these patients with concurrent constipation have also noted improved stool frequency and rectal evacuation. Eight women (median age 47 years, median symptom duration 31 years, median stool frequency once per 6 days) were implanted with a temporary percutaneous stimulating S3 electrode for 3 weeks, attached to an external stimulator (Medtronic, Minneapolis,USA). A bowel symptom diary card, anorectal physiological studies, and a radiopaque marker transit study were completed before and during stimulation. Two patients had cessation or marked diminution of symptoms, including normalization of bowel frequency. Colonic transit did not return to normal in any patient. Rectal sensory threshold to distension was decreased during stimulation. Percutaneous temporary sacral nerve stimulation symptomatically improved a minority of patients with resistant idiopathic slow transit constipation. Sensory function was altered by stimulation. Further studies are required to identify patients who may benefit and to assess a range of stimulation parameters.

Adult↗
PubMed2001

Origin and make up of the human sural nerve.

The dissection of 37 cadavers has shown that in only a third of cases, the sural nerve comes from the communication between the medial cutaneous nerve, derived from the tibial nerve, and the communicating branch of the lateral cutaneous nerve of the leg which comes from the lateral popliteal nerve. The communication is most often at the junction between the proximal two-thirds and distal third of the leg, on average 2 mm below the transverse crease of the popliteal fossa. The medial cutaneous nerve was absent in only one case. On the other hand, in 11 cases the lateral cutaneous nerve or its communicating branch was missing. In 12 cases without any anastomoses, the route of the sural nerve was followed by the medial cutaneous nerve of the leg in 9 cases and by the lateral cutaneous nerve in 3 cases. The majority of branches to the proximal half of the calf came from the lateral cutaneous nerve. In the lower part of the leg, the sural nerve and/or the medial cutaneous nerve gave numerous branches to the Achilles' tendon and to the integuments of the lateral aspect of the heel and lateral malleolus.

Cadaver↗
PubMed2003

Segmental nerve damage during a McBurney's incision: a cadaveric study.

Injury to the ilioinguinal and iliohypogastric nerves after a McBurney's incision have been reported to cause paralysis of the conjoint tendon that may lead to the development of an indirect inguinal hernia. This study reports on the incidence of ilioinguinal and iliohypogastric nerve sectioning after the performance of a classic McBurney's incision as well as the distance and relationship of the ilioinguinal and iliohypogastric nerves to the anterior superior iliac spine and a classic McBurney's incision. The right iliac fossa and lumbar region of 33 cadavers were dissected for the uncovering of the ilioinguinal and iliohypogastric nerves after a correct McBurney's incision was made. Injury to the ilioinguinal and iliohypogastric nerves was recorded. The mean distance between the ilioinguinal nerve and the incision line was 41.89 mm and 34.63 mm between the iliohypogastric nerve and the incision line. The ilioinguinal and iliohypogastric nerves were found to be 6.69 mm and 12.08 mm from the anterior superior iliac spine, respectively. No ilioinguinal or iliohypogastric nerve was injured during all 33 McBurney's incisions.

Cadaver↗
PubMed2000

CT-guided intervention using a patient laser marker system.

To prove the usefulness of a simple laser marker system (LMS) in target definition as well as examination procedure for CT-guided interventions, 130 cases of diagnostic biopsies and lumbal sympathectomies were compared. In 75 cases LMS and in 55 cases a simple crossgrid was used. Taking advantage of the LMS, the parameters of intervention (cutaneous location, length, and angle) can be planned, exactly demonstrated, and it is possible to check the needle position during the whole procedure. Thus, the number of necessary control scans decreased to 30%, and corrections of needle location were reduced to approximately 30%. Moreover, the average target deviation of the needle decreased below 5 mm in 50% of cases, and the duration of interventional procedure was reduced considerably. It can be concluded that LMSs are recommended in CT-guided interventions for quality assurance, dose reduction, and improvement of handling. It will be especially advantageous in cases of small target volume, oblique needle path, and tilted gantry.

Biopsy, Needle↗
PubMed2002

Electrophysiological recordings during the peripheral nerve evaluation (PNE) test in complete spinal cord injury patients.

Up until now, the exact mechanism by which neuromodulation using sacral nerve stimulation works still remains unknown. Recent studies of pelvic floor contraction during peripheral nerve evaluation (PNE) have shown that several muscle responses are reflexly mediated. However, whether these reflexes originate from a segmental level within the sacral spinal cord or from supraspinal neuronal centers involving spino-bulbospinal pathways remains to be determined. Therefore, recordings of external anal sphincter reflexes during PNE in complete spinal cord injury (SCI) patients was performed. Three patients with complete SCI (two female and one male) suffering from neurogenic incontinence underwent the first stage of a stimulator implant (peripheral nerve evaluation). Stimulation was obtained through an electrode placed in the S3 foramen. Concomitantly, the latency of the response of the striated anal sphincter was measured using a concentric needle electrode placed in the striated part of the anal sphincter. Repeated measurements within an interval of 30 min were performed to confirm the reliability of the responses. In all subjects, reflex responses of early and late latencies could be recorded. The early response showed a mean latency of 41.2 ms (range 33.3-62 ms), which corresponds to a segmental reflex, similar to the pudendo-anal reflex. The late response appeared with a mean latency of 189.4 ms (range: 183.3-197.8 ms) and with high variability and fatigability, suggesting a reflex response organized at polysegmental spinal levels. Despite successful foramina lead placement, none of our complete SCI patients showed any improvement of neurogenic incontinence after 5 days of treatment by sacral nerve stimulation. The findings confirm that the anal contractions observed during peripheral nerve evaluation are reflex responses mediated by afferent pathways. Both the early and late reflex responses are of spinal origin, since they were obtained in complete SCI patients in whom all spino-bulbo spinal loops are supposed to be interrupted. The finding that neuromodulation is working in non-neurogenic patients but is less successful in complete SCI patients could give evidence that preserved spino-bulbo spinal loops contribute to the positive effects of neuromodulation. The role of an eventual spino-bulbo spinal loop acting during neuromodulation in non-neurogenic patients has to be assessed in further studies.

Adolescent↗
PubMed2003

The role of the carbachol test and concomitant diseases in patients with nonobstructive urinary retention undergoing sacral neuromodulation.

The aim of this study was to evaluate the percutaneous nerve evaluation (PNE) test success in patients with nonobstructive urinary retention. A total of 24 PNE tests were performed in patients with nonobstructive urinary retention and in 18 patients, a carbachol test was performed during urodynamics. The diagnosis relating to the acontractile detrusor was also assessed and compared to the outcome of the PNE test. The PNE test was successful in eight of 24 patients (33.3%) with the the highest success rate being observed in patients after hysterectomy (80%). It was successful in five of 12 patients with negative carbachol tests and in three of six patients with positive carbachol tests. We conclude that sacral neuromodulation is an effective treatment option in patients with nonobstructive urinary retention. PNE tests should be performed in all patients with therapy resistant nonobstructive urinary retention, because predictive factors do not exist.

Adult↗
PubMed1998

Surgery for detrusor overactivity.

Intractable detrusor overactivity can result in considerable morbidity and, in the case of neurogenic bladder dysfunction, can put the upper tracts at risk. Once conservative treatments have been exhausted the aim of surgery is to increase functional bladder capacity and decrease the maximal detrusor pressure at this capacity. The mainstay of contemporary therapy has been augmentation cystoplasty; the different techniques and recent literature are reviewed herein. Bladder autoaugmentation is compared and contrasted with augmentation cystoplasty and its role is discussed, as is the less invasive technique of sacral neuromodulation with reference to their role within the range of surgical treatments for detrusor activity.

Animals↗
PubMed2002

Bilateral sacral spinal nerve stimulation for fecal incontinence after low anterior rectum resection.

BACKGROUND AND AIMS: The somatomotor innervation pattern has been shown to differ in patients undergoing percutaneous nerve evaluation for sacral nerve stimulation. In some patients bilateral stimulation might improve clinical outcome; however, only single-channel pulse generators have until now been available. We report a patient with fecal incontinence after surgery for rectal carcinoma in whom a dual-channel, individually programmable, pulse generator permitted implantation of neurostimulation electrodes bilaterally. PATIENTS AND METHODS: Intractable fecal incontinence developed in a 48-year-old man who underwent low anterior rectum resection, owing mainly to reduced internal anal sphincter function. The morphology of the anal sphincter was without defect. Based on the findings of unilateral and bilateral temporary sacral nerve stimulation the patient underwent placement of foramen electrodes on S4 bilaterally. Both electrodes were connected to a dual-channel impulse generator for permanent low-frequency stimulation. RESULTS: The percentage of incontinent bowel movements decreased during unilateral test stimulation from 37% to 11%, during bilateral test stimulation to 4%, and with chronic bilateral stimulation to 0%. The Wexner continence score improved from 17 preoperatively to 2, and quality of life (ASCRS score) was notably enhanced. Anorectal manometry revealed improved striated anal sphincter function; the internal anal sphincter remained unaffected. CONCLUSION: Sacral nerve stimulation can effectively treat incontinence after rectal resection, and bilateral stimulation can improve the therapeutic effect.

Electric Stimulation Therapy↗
PubMed2003

Permanent sacral nerve modulation for fecal incontinence and associated urinary disturbances.

BACKGROUND AND AIMS: Sacral nerve modulation (SNM) using an implantable pulse generator is gaining increasing acceptance in the treatment of several functional disturbances of the urinary and intestinal tract. This new therapeutic approach offers new possibilities in the treatment of fecal incontinence (FI) by means of its possible effects on anorectal physiology. PATIENTS AND METHODS: Fourteen patients with FI, six of whom had associated urinary disturbances, underwent permanent SNM after successful peripheral nerve evaluation tests. All had a clinical evaluation including FI grading systems (American Medical systems, AMS; Continence Grading System, CGS) and quality of life questionnaires (Fecal Incontinence Quality of Life, FIQL), and anorectal physiology tests performed before and during electrostimulation. Two patients had a lead displacement which was repositioned. Median follow-up was 14 months (range 6-48 months). RESULTS: AMS scores decreased significantly from 101 to 67 after 24 months CGS scores from 15 to 2 after 2 months. The median number of episodes of major incontinence per 2 weeks decreased from 14 to 1 after 24 months. FIQL scores improved significantly in the nine patients tested from an overall score of 1.59 to 3.3, with improvement in all areas of the FIQL. Four of the six patients with associated urinary disturbances had a significant improvement in their symptoms. Anal resting and squeezing tone did not change significantly, nor did rectal volumetry, compliance, rectoanal inhibitory reflex, or length of the anal high-pressure zone, while 24-h rectal manometry showed inhibition of the spontaneous rectal motility complexes after meal and on awakening in the only two patients undergoing this investigation. CONCLUSION: Although the mechanism of action of SMN is still unclear and requires further investigations, clinical results are very encouraging, confirming the role of this new and safe procedure in the treatment of FI and associated urinary disturbances.

Adult↗
PubMed2001

Laparoscopic lumbar sympathectomy for lower-limb disease.

BACKGROUND: The standard procedure for sympathectomy is open surgery. The oblique retroperitoneal approach is popular because it provides good visibility, albeit at the expense of requiring a long skin incision. Chemical sympathectomy has been introduced as a less invasive means of achieving sympatholysis; however, this method is also associated with a significant incidence of incomplete block and transient denervation. Laparoscopic surgery is a new approach that simplifies various surgical procedures. The aim of our report was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. METHODS: Between March 1997 and April 2000, seven patients underwent laparoscopic lumbar sympathectomy in our department (all men, with an average age or 45.1 years). The predominant presenting symptoms were unilateral pain at rest and lower-extremity coldness. Symphaectomy was performed using a retroperitoneal approach on six patients and an anterior transperitoneal approach on one patient. After laparoscopic lumbar sympathectomy, skin thermometry was carried out on all patients. RESULTS: The postoperative skin temperature of the affected leg rose to 36.6 +/- 0.5 degrees C, as compared to 33.8 +/- 0.8 degrees C preoperatively. After laparoscopic lumbar sympathectomy, none of the patients complained of neuralgia. All patients achieved sustained symptomatic relief, and no major postoperative complications were noted. CONCLUSIONS: Lumbar sympathectomy can be performed laparoscopically. Currently, our standard technique is the retroperitoneal approach. More clinical experience and long-term follow-up will ultimately determine if this will become the procedure of choice. However, we believe that a learning period is necessary for this technique to be fully mastered.

Adult↗
PubMed2003

In utero exposure to nonsteroidal anti-inflammatory drugs: neonatal renal failure.

We report a case of neonatal transient renal failure after maternal ingestion of diclofenac, paracetamol, and nimesulide during pregnancy. The baby girl was delivered at the 33 weeks gestation for complete absence of amniotic fluid. Acute renal failure was present. Urine output started 12 h after birth, increasing to polyuria on day 6, and then decreasing gradually to normal values. Serum creatinine normalized on day 6. Several cases of severe and sometimes irreversible renal problems have been described in neonates exposed to indomethacin, a non-selective cyclooxgenase (COX) inhibitor, during their fetal life. More recently, the use of nimesulide, a selective COX-2 inhibitor, as a tocolytic agent has been advocated. Although it is difficult to ascribe the observed side effects to one specific drug in our patient, using the Naranjo ADR probability scale, renal failure was probably related to nimesulide exposure. Paracetamol is considered safe at therapeutic doses, and there are no reports of prenatal diclofenac toxicity. However, recently there have been some reports of neonatal renal failure associated with maternal nimesulide consumption and probably modulated by genetic factors. Hence, cautious use of nimesulide during pregnancy must be advocated.

Acetaminophen↗
PubMed1999

When all else fails: stepwise multiple solutions for a complex cancer pain syndrome.

In the presence of insufficient pain relief and substantial adverse effects, application of alternative routes of administration and a change of opioid are the main methods used to improve the analgesic response. When all else fails, the result may further be optimized using adjuvant drugs by an alternative route, namely the intrathecal route. A stepwise approach with multiple drugs and routes of administration is described. This was implemented to resolve a complex pain syndrome otherwise considered uncontrollable. We found it possible to manage a very difficult pain situation by intrathecal home infusion through the efforts of a well-trained family and GP and a continuous exchange of information and advice with the pain relief team about changes in therapy to adapt to the clinical situation. A stepwise and a meaningful approach to clinical problems with use of advanced techniques and alternative drugs in the patient's home may be helpful in the treatment of conditions otherwise considered intractable.

Aged↗
PubMed2004

Ropivacaine produces sensory blockade in the lumbar sacral region more frequently than mepivacaine in lower thoracic epidural anesthesia.

PURPOSE: The first sacral nerve has the largest diameter among the spinal nerves and is resistant to local anesthetics. Ropivacaine is a newly developed local anesthetic. There is a possibility that a difference in chemical properties between ropivacaine and other local anesthetics produces a difference in the blockade of the S1 dermatome by lower thoracic epidural anesthesia. Mepivacaine, 2%, is frequently used for epidural anesthesia and produces a level of blockade similar to that of bupivacaine, 0.5%. The purpose of this study was to examine the sensory blockade in the sacral region induced by ropivacaine with that induced by mepivacaine administered in the lower thoracic epidural space. METHODS: Eighteen adults undergoing lower thoracic epidural anesthesia (thoracic 11/12 interspace) were studied in a double-blind fashion. Patients were assigned to one of two groups: those who received 2% mepivacaine, 18 ml (group M; n = 9), and those who received 1% ropivacaine, 12 ml (group R; n = 9). The cephalad levels of sensory blockade to cold, pinprick, and touch in the L2, S1, and S3 dermatomes were assessed at 10, 20, and 35 min after injection. RESULTS: There were no differences in the cephalad levels of sensory block to cold (T4 [range, T4-T2] and T4 [range, T6-T2]), pinprick (T4 [range, T6-T4] and T4 [range, T6-T4]), or touch (T6 [range, T6-T4] and T6 [range, T6-T4]) between group M and group R respectively, at 35 min (P > 0.05). In the L2 and S3 dermatomes, there were no significant differences in the numbers of patients who obtained sensory block to cold or pinprick at 20 and 35 min after study drug administration. However, in the S1 dermatome, significantly higher numbers of patients in group R obtained sensory block to cold at 20 and 35 min after study drug administration than in group M (8 and 0; 9 and 0; P = 0.001 and P < 0.001; 20 min and 35 min after administration, respectively). Also in the S1 dermatome, significantly higher numbers of patients in group R obtained sensory block to pinprick at 20 and 35 min after study drug administration than in group M (6 and 0; 9 and 0; P = 0.027 and P < 0.001; 20 min and 35 min after administration, respectively). A significantly higher number of patients in group R had sensory block to touch in the S3 dermatome at 35 min (7 and 2; group R and group M, respectively; P = 0.01). CONCLUSION: Ropivacaine, 1%, administered in the lower thoracic epidural space, induces sensory blockade to cold and pinprick in the S1 dermatome more frequently than 2% mepivacaine.

Adult↗
PubMed2003

Remodelling of the sacrum in high-grade spondylolisthesis: a report of two cases.

Two young patients are described, who were operated on for high-grade spondylolisthesis. A good posterolateral fusion was achieved, without decompression and without reduction. The clinical course was favourable, the tight hamstring syndrome resolved. Disappearance of the posterior-superior part of the sacrum and of the posterior part of the L5-S1 disc was observed on comparing pre- and postoperative magnetic resonance (MR) images. This resulted in normalisation of the width of the spinal canal. Around the L5 nerve roots in the L5-S1 foramina some fat reappeared. These anatomical changes on MRI could play a role in the disappearance of clinical symptoms.

Adolescent↗
PubMed2006

Segmental overlap: foot drop in S1 radiculopathy.

Knowledge of segmental innervation of skeletal muscles is essential for diagnosing lumbar radiculopathy. Myotomes and dermatomes are traditionally thought to be innervated by a single spinal segment, but experimental studies have shown that this pattern of segmental innervation allows considerable overlap. This implies that muscles (or dermatomes) are innervated not only by axons of one spinal segment, but also partially by axons of adjacent spinal levels. We describe a patient in whom overlap in segmental innervation complicated adequate diagnosis of a recurrent lumbar hernia. Further, we present an outline of electrophysiological and anatomical studies on segmental innervation.

Diskectomy↗
PubMed2006

Video-assisted sacral nerve stimulation.

BACKGROUND: Sacral nerve simulation (SNS) is an accepted therapy for patients with urinary or bowel dysfunction. However, infection rates are as high as 20% and can result in removal of the expensive device. We present a new video-assisted technique minimizing the risk of infection. METHODS: Between April and July 2005, six consecutive women of median age 68 years (range, 60-74), with faecal incontinence (4 patients) and idiopathic constipation (2 patients) underwent video-assisted electrode implantation for SNS. The motor response of the pelvic floor during percutaneous nerve evaluation and implantation of the permanent lead was monitored by a video optic (same as that normally used for laparoscopic or endoscopic procedures) placed between the legs of the patients. The video optic and the perianal area were completely covered with drapes, separating them from the operating field. RESULTS: All but one screening was successful, and no wound infections at the electrode or at the pocket of the stimulator were noted (mean postoperative follow-up, 8 weeks). CONCLUSIONS: With the use of a video optic, the anus and the implantation site can be completely separated and contamination during the operation becomes unlikely. Furthermore, the response of the pelvic floor to the stimulation is better visualized. We routinely recommend the use of video equipment for SNS electrode implantation.

Aged↗
PubMed2002

Sacral nerve neuromodulation improves physical, psychological and social quality of life in patients with fecal incontinence.

There are several therapeutic options for fecal incontinence but often they do not achieve good results in the long run. This study dealt with sacral nerve modulation, a new therapeutic option. Twenty-one patients underwent pudendal nerve evaluation (PNE) at our institution. Nine patients were affected by both fecal and urinary incontinence, 3 had fecal incontinence and anal pain, 5 had fecal incontinence and pelvic floor dyssynergia, and 4 had isolated fecal incontinence. They underwent morphological, functional and psychological tests prior to PNE, showing no sphincter rupture, almost normal anal pressures, impaired rectal sensation and deficient psychological pattern. All patients underwent at least two nerve evaluations. Four of 21 patients (19%) were selected to receive a permanent sacral electrode, as PNE seemed to have improved their symptoms by >75%. A median follow-up of 15 months (range, 6-24 months) showed that this method decreases weekly episodes of incontinence and increases maximal squeeze pressure. We demonstrated an increase in basal pressure in 3 of 4 patients (all with isolated fecal incontinence). Rectal sensation threshold decreased in three patients; urge threshold decreased in two patients and increased in two patients, but in each patient we got a stabilization. We evaluated the quality of life by applying the Short Form Health Survey test (SF-36). All 4 patients showed a significant increase in the scores of physical, emotional and social role functioning after the permanent implant. In conclusion, sacral nerve modulation may improve physical, physiological and social quality of life in selected groups of incontinent patients without gross sphincter lesions and with impaired rectal sensation.

Adult↗