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PubMed2005

[Idiopathic lumbosacral plexopathy].

INTRODUCTION: Lumbosacral plexopathy is the equivalent in the lower limbs of neuralgic amyotrophy (also known as Parsonage-Turner syndrome) in the upper limbs. It is well-known in patients with diabetes mellitus, when it is known as Bruns-Garland syndrome. CASE: We report the case of a 47-year-old woman who developed a unilateral neuropathy of the leg, neither radicular nor truncal in origin. The slow continuous improvement was not affected by any of the treatments administered. DISCUSSION: Lumbosacral plexopathy is characterized by intense pain in one or both legs, associated with motor and sensory deficits. Recovery is usually slow (6 to 36 months) and often incomplete. The electrodiagnostic examination shows important acute motor and sensory axonal loss, characterized by denervation and low-amplitude sensory action potential. Treatment generally combines analgesics with narcotic agents, neuropathic pain medication, short-term corticosteroids, and rehabilitation. In the most severe cases, long-term corticosteroids and other immunosuppressive agents may be required. This diagnosis cannot be reached until all other radicular, plexal and truncal origins have been ruled out.

Female↗
PubMed2003

Sacral neuromodulation for chronic pain conditions.

Some of the pelvic pain syndromes seem to have features of neurogenic inflammation and neuropathic pain in common. As opposed to being separate disease entities, they may represent a spectrum of clinical presentations of CRPS I of the pelvis. Sacral nerve root stimulation provides good symptomatic relief of pain and voiding dysfunction. The techniques of retrograde root stimulation may offer superior results with fewer complications and lead migrations when compared with other methods. Perhaps neuromodulation should be used earlier in the treatment paradigm for these disorders, before the potentially injurious procedures of hydrodistention, bladder installations, and cystectomies.

Adult↗
PubMed1999

High dietary salt enhances acute depressor responses to metformin.

The antidiabetic drug metformin lowers blood pressure (BP) more in spontaneously hypertensive rats (SHR) compared with Wistar-Kyoto rats (WKY), and the hypotensive effect is enhanced by high dietary salt. To determine whether enhanced hypotension is secondary to greater decreases in sympathetic nerve activity (SNA), we placed WKY and SHR on normal salt (0.3%), and SHR on high salt (8.0%) for 2 weeks and then measured anesthetized BP and lumbar SNA to metformin (0, 10, 50, and 100 mg/kg, given intravenously). Baseline BP were similar in SHR groups but lower in WKY. Although metformin decreased BP more in high salt SHR (50 mg/kg: deltaBP: -23+/-1 mm Hg) than in normal salt SHR (-14+/-1 mm Hg, P< .01) and less in WKY (-10+/-1 mm Hg, P<.05), equivalent decreases in SNA were observed. We conclude that both strain and high salt potentiate acute depressor responses to metformin through mechanisms that are independent of SNA.

Animals↗
PubMed2004

Prostaglandin E1 versus lumbar sympathectomy in the treatment of peripheral arterial occlusive disease: randomised study of 86 patients.

BACKGROUND AND AIM: The aim of this study was to compare the effects of a pharmacological and a surgical vasodilatatory therapy in the treatment of chronic arterial diseases of the lower limbs. METHODS AND RESULTS: After giving their informed consent, 40 patients were randomised to receive a slow (approximately 2-hour) infusion of 40 microg of prostaglandin E1 twice daily for 28 days (group A), and 46 were randomised to undergo lumbar sympathectomy, including the second and third ganglion. Twenty-four (60%) of the patients in group A experienced complete remission, seven (17.5%) were partial responders, and nine (22.5%) failed to respond. Of the 46 patients in group B, 29 (63%) experienced complete remission, seven (15.2%) were partial responders, and 10 (21.7%) failed to respond. CONCLUSIONS: Broadly similar results were obtained with the two types of treatment, both of which are indicated mainly in Fontaine stages IIB and III (non-advanced), particularly when revascularising therapy is impossible or excessively risky. The two strategies can be advantageously combined with direct revascularisation surgery and may therefore constitute a first-line approach favouring subsequent therapy.

Aged↗
PubMed1999

Lumbar sympathectomy in critical limb ischaemia: surgical, chemical or not at all?

The value of surgical and chemical lumbar sympathectomy was studied in patients with critical lower-limb ischaemia without the option of vascular reconstruction. Clinical success rates, defined as improvement of ischaemia stage, and limb salvage rates were recorded for 76 limbs of 70 consecutive patients. Chemical lumbar sympathectomy patients were older and had more concomitant diseases than surgical lumbar sympathectomy patients. The short-term (6-week) success rate in 36 cases treated with surgical lumbar sympathectomy (44%) was better than in 40 cases treated with chemical lumbar sympathectomy (18%) (P = 0.01). The long-term (1-year) success rate was 47% for surgical lumbar sympathectomy and 45% for chemical lumbar sympathectomy (P = NS). The 1-year limb salvage rates were 61% for surgical lumbar sympathectomy and 58% for chemical lumbar sympathectomy (P = NS). Complications were minor in both groups. Lumbar sympathectomy still has a limited role in the treatment of critical limb ischaemia in patients without the option of vascular reconstruction. Both surgical and chemical lumbar sympathectomy can be performed with very little morbidity and may provide a benefit over the natural course of the arterial insufficiency.

Arterial Occlusive Diseases↗
PubMed1998

Lumbar sympathectomy performed by means of videoscopy.

Sympathetic denervation has fallen into disfavour for operations. Dorso-perivertebral, paravertebral or retroperitoneal approaches are only of historic importance. The oblique retroperitoneal approach is popular because it provides good visibility, at the expense of a long skin incision. A videoscopic procedure has now been developed for lumbar sympathectomy. A transverse skin incision of 3-4 cm is made in the hypochondrium, lateral to the rectus sheath. The abdominal muscles are split along their fibres. The transversalis fascia is opened and the peritoneum is carefully peeled back. A trocar is then introduced laterally from the skin incision, and under visual control the sympathetic trunk is exposed. After identifying the ganglia, L2 and L3 are coagulated together with the part of the sympathetic trunk that joins them. The suction drainage is not required nor are balloons to develop the operation field, which is not insufflated. Patients undergo rehabilitation much more easily because of reduced wound pain and they leave hospital quickly. The method only requires basic videoscopy instruments.

Endoscopy↗
PubMed1999

The changes seen in balloon-injured porcine femoral arteries following sympathectomy.

On the basis that vasoconstriction may contribute to restenosis following angioplasty, the influence of lumbar sympathectomy on the morphometry of femoral arteries after balloon injury was examined in a pig model. Twenty-six juvenile pigs underwent balloon de-endothelialization of the right femoral artery followed by an open bilateral lumbar sympathectomy (n = 14) or a sham sympathectomy (n = 12). Four weeks later flow was measured in femoral arteries. Animals were then killed and the femoral arteries were perfusion-fixed and harvested. Sympathectomy resulted in a significant (P = 0.04) increase in flow in both the injured (right) and uninjured (left) femoral arteries. Sympathectomy did not inhibit intimal thickening following balloon injury: median (interquartile range) intimal area was 0.4 mm2 (0.3-0.9) in the sympathectomy group versus 0.5 mm2 (0.4-0.9) in the sham group. Sympathectomy did, however, result in a significant (P = 0.02) increase in the lumen area: 1.1 mm2 (0.8-1.8) versus 0.7 mm2 (0.6-0.9). Sympathectomy may reduce vasospasm following angioplasty with the potential for clinical benefit.

Animals↗
PubMed1997

Hyperglycemia, lumbar plexopathy and hypokalemic rhabdomyolysis complicating Conn's syndrome.

BACKGROUND: Lumbosacral plexopathy is a complication of diabetes mellitus. Conn's syndrome from an aldosterone secreting adenoma may be associated with hypokalemia and rhabdomyolysis but mild hyperglycemia also usually occurs. METHODS: Case description. RESULTS: A 70-year-old male diagnosed as having Conn's syndrome, hypokalemia and mild hyperglycemia developed rhabdomyolysis and lumbar plexopathy as a presenting feature of his hyperaldosteronism. His rhabdomyolysis rapidly cleared following correction of hypokalemia but recovery from the plexopathy occurred slowly over several months. Definite resection of the aldosterone secreting adenomas reversed the hyperglycemia. CONCLUSIONS: Our patient developed lumbar plexopathy resembling that associated with diabetes mellitus despite the presence of only mild and transient hyperglycemia.

Aged↗
PubMed1977

Lumbo-sacral radiculopathy induced by radiation.

Two patients had lumbo-sacral radiculopathy following radiation treatment of cancer. Twenty previously reported cases were similar. The clinical picture is one of progressive motor and sensory loss in the legs, usually appearing within a year after radiation, but sometimes delayed up to several years. Experimental studies quoted indicate greater vulnerability of peripheral nerves to ionizing radiation than has been previously recognized. Lumbo-sacral radiculopathy is readily produced in the experimental animal (rat) and affords an experimental model closely resembling the human cases reported.

Carcinoma, Squamous Cell↗
PubMed2002

Diagnostic value of electrical stimulation of lumbosacral roots in lumbar spinal stenosis.

OBJECTIVES: This paper compares the diagnostic sensitivity of two tests in lumbar spinal stenosis (LSS): lumbosacral root stimulation with needle electrodes and needle electromyograph (EMG). MATERIAL AND METHODS: Twenty patients with LSS were assigned to two groups: Patients with 'neurogenic intermittent claudication' (NIC) only (n=11), and patients with 'neurological signs' (n=9). Ten normal subjects were also examined. The effects of direct stimulation of the lumbosacral roots and conventional EMG recorded from important muscles [rectus femoris (RF): L4, tibialis anterior (TA): L5, soleus muscle (SOL): S1], were compared with each other and correlated with their respective clinical findings and radiological images. RESULTS: Needle EMG and nerve conduction study revealed pathology in 15/20 patients, and electrical stimulation of the roots in 17/20 patients. Agreement in radiological findings with electrical stimulation of the roots and EMG was found in 12 patients. The other patients were harmonic with radiological findings either in EMG or in electrical stimulation of the roots. CONCLUSIONS: Electrical root stimulation revealed more abnormalities in patients with LSS in comparison with needle EMG. However, both methods seemed to complement each other to show additional pathology in a given patient.

Adult↗
PubMed2003

Failure of immunotherapy to prevent, arrest or reverse diabetic lumbosacral plexopathy.

Three patients are described who had severe and progressive diabetic lumbosacral plexopathy despite active immunosuppressive therapy. One patient developed the condition while immunosuppressed for a cardiac transplant and two others progressed while receiving intravenous gamma globulin. The cases raise questions about current unsupported practices of treatment for this condition. Robust clinical trial evidence is required before immunosuppression can be recommended.

Adult↗
PubMed1975

The peripheral unconditioned stimulus pathway in a model learning system involving defensively conditioned heart rate change in the pigeon.

The peripheral pathway transmitting the unconditioned stimulus information is described in a vertebrate model system for studying learning-visually conditioned heart rate change in the pigeon. In this system footshock serves as the unconditioned stimulus, and it is shown that the effective stimulation field of this stimulus, defined with respect to the unconditioned cardioacceleratory response, includes cutaneous dermatomes 21-25 (L1-Sl). The stimulus information is then transmitted by Group III and IV fibers in portions of the femoral and sciatic nerves which enter the spinal cord over segments 21-25. Further, it is shown that interrupting this pathway by section of dorsal roots 21-25 precludes establishing conditioned heart rate change with footshock as the unconditioned stimulus.

Action Potentials↗
PubMed1987

Post-surgical ischaemic myelopathy.

Ischaemic myelopathy is an infrequent but well-known cause of spinal cord injury. While the overall incidence of neurological injury following thoraco-abdominal aortic surgery is low (1-14%), procedures requiring surgical cross-clamping of the aorta have been reported as the major cause of ischaemic cord injury (31%). Little has been reported regarding the clinical and functional outcomes of these injuries. Three patients with a non-penetrating aortic injury who showed evidence of ischaemic cord injury within 72 hours of surgical cross-clamping of the aorta are presented. Data includes functional assessments, muscle strength testing and electromyographic findings. All three patients showed lower thoracic incomplete motor and sensory spinal cord injuries. These findings suggest that, after a period of neurological improvement, a plateau phase is reached at approximately 3 months post injury after which no significant gain in muscle strength is made. All patients were functionally independent and able to ambulate using a straight cane.

Adult↗
PubMed1988

Effects of cisapride on constipation due to a neurological lesion.

Two patients with intractable constipation and an atonic bladder due to a partial spinal cord lesion and sacral nerve lesion are described. Treatment with cisapride (4 x 10 mg daily) was undertaken. After a few days the stool passed spontaneously. The effect was dose-dependent and has been maintained for at least 40 months. Normal bladder function was not achieved.

Adult↗
PubMed1991

Ischaemic lumbosacral plexopathy in acute vascular compromise: case report.

Anterior spinal artery syndrome (ASAS) is a well reported cause of spinal cord injury (SCI) following thoracoabdominal aortic surgery. The resultant deficits are often incomplete, typically attributed to the variable nature of the vascular distribution. Our Physical Medicine and Rehabilitation (PM and Rehabilitation) service was consulted about a 36-year-old patient with generalised deconditioning, 3 months after a stab wound to the left ventricle. Physical examination revealed marked lower extremity weakness, hypotonia, hyporeflexia, and a functioning bowel and bladder. Further questioning disclosed lower extremity dysesthesias. Nerve conduction studies showed slowed velocities, prolonged distal latencies and decreased amplitudes of all lower extremity nerves. Electromyography revealed denervation of all proximal and distal lower extremity musculature, with normal paraspinalis. Upper extremity studies were normal. Recently, 3 cases of ischaemic lumbosacral plexopathy, mimicking an incomplete SCI, have been reported. This distinction is particularly difficult in the polytrauma patient with multiple musculoskeletal injuries or prolonged recuperation time, in addition to a vascular insult, as in this patient. The involved anatomical considerations will be discussed. A review of the electrodiagnostic data from 30 patients, with lower extremity weakness following acute ischaemia, revealed a 20% incidence of spinal cord compromise, but no evidence of a plexopathy.

Adult↗
PubMed1997

Treatment of external urethral sphincter hypertonicity by pudendal nerve block using phenol solution in patients with spinal cord injury.

We report our experience utilizing the technique of phenol block of the pudendal nerve in the treatment of voiding dysfunction due to hypertonicity of the external urethral sphincter. We have performed 13 pudendal nerve blocks using a 7% phenol solution in seven patients with spinal cord injury who could not obtain relaxation of the external urethral sphincter with a large postvoid urine residual (150 ml to 600 ml) despite large doses of antispasticity drugs and intermittent catheterisations over three weeks. These drugs were discontinued at least 48 hours before this procedure. The efficacy of the pudendal nerve block could also be tested by the ease of facilitating micturition during or just after the block and measuring the amount of postvoid residual urine and intravesical leak pressure. A pudendal nerve block was produced by injecting a 7% phenol solution medial to the ischial tuberosity having specifically localized the nerve by electrical stimulation. This procedure improved the voiding pattern dramatically, leading to a full stream of urine and a remarkable decrease of postvoid residual volume and intravesical leak pressure. The mean difference of the postvoid residual volume and the intravesical leak pressure before and after pudendal nerve block was 255.7 ml and 57.5 cmH2O, respectively. We conclude that pudendal nerve block with a phenol solution as a treatment of external urethral sphincter hypertonicity was effective, easy to perform, and had no complication. This treatment should be considered as a possible alternative to more invasive surgical procedures.

Adult↗