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PubMed2006

A randomized trial of intravenous iloprost (a stable prostacyclin analogue) versus lumbar sympathectomy in the management of Buerger's disease.

AIM: The aim of this study was to compare the effects of iloprost and lumbar sympathectomy (LS) in the treatment of Buerger's disease. METHODS: Two hundred patients with rest pain and/or ischemic ulcers were randomized to undergo LS or 28-day intravenous treatment of iloprost. The primary endpoint was complete healing without pain or major amputation at 4 and 24 weeks. The secondary endpoints were analgesic requirement, reduction in the ulcer size, 50% reduction of the ulcer, and shift in the modified SVS/ISCVS clinical status grading scale. RESULTS: The comparison was carried out in 162 patients (iloprost: n=84; LS: n=78). Complete healing rate was 61.9% in the iloprost group, but 41% in the LS group at the 4th week (P=0.012); respective values for the 24th week were 85.3%, 52.3%, P<0.001. Analgesic requirement was lower in the iloprost group at the 4th and 24th weeks (P=0.01, and P=0.098, respectively). The size of the ulcers decreased more in the iloprost group than the LS group (P=0.044 and P=0.035 at 4th and 24th weeks); 50% reduction in the ulcer size in the iloprost group was greater than in the LS group (P=0.001 and P=0.009 at 4th and 24th weeks). SVS/ISCVS grading scale demonstrated a better clinical benefit in patients treated with iloprost (P<0.001 at 4th week, and P<0.001 and at 24th week). CONCLUSIONS: The results of this independent study indicate that using iloprost relieves ischemic symptoms better than LS. In the era of stable prostacyclin analogues, there is no reliable evidence to support the use of LS in Buerger's disease.

Adult↗
PubMed2006

The current use of neuromodulation for bladder dysfunction.

Neuromodulation utilizes electrical stimulation to alter the function of an organ. Recent advances in technology and improved knowledge of micturition physiology have coincided with the growth of neuromodulation for the treatment of urinary urgency/frequency, urge incontinence and non-obstructive urinary retention. Currently, the most common modality for bladder neuromodulation involves stimulation through the S3 foramen, or sacral neuromodulation. This review will highlight the current indications, patients selection, implantation options/techniques, outcomes and complications of sacral neuromodulation. In addition, other methods of neuromodulation will be discussed.

Electric Stimulation Therapy↗
PubMed2006

Lumbosacral nerve root avulsions: MR imaging demonstration of acute abnormalities.

Most of the previously reported lumbosacral nerve root avulsions presented with pseudomeningoceles at the time of delayed initial imaging. We report a case of traumatic lumbosacral nerve root injury associated with an isolated femur fracture and demonstrate the evolution of pseudomeningoceles following nerve root avulsions and edema in the perineural fat identified on the initial MR imaging.

Accidents, Traffic↗
PubMed2006

[Sacral staged reflexes to localize the pudendal compression: an anatomical validation of the concept].

Pudendal neuropathy is common. The diagnosis is clinical and the confirmation is electrophysiological. Distal pudendal nerve latencies have been used but they are unspecific and do not allow to localize the site of compression. A preliminary electrophysiological study has suggested separate innervations of the anterior and the posterior anal sphincter quadrants, so diverging from what main anatomy textbooks teach. By detailed dissections of pudendal nerve region we can confirm a dichotomy in the innervation of the two quadrants. Therefore, it seems feasible, by using the differences of staged sacral reflexes, to better localize the compressive neuropathy, with a stimulation of the clitoris and by recording latencies of different muscles.

Cadaver↗
PubMed2006

Retroperitoneoscopic lumbar sympathectomy for nonreconstructable arterial occlusive disease.

AIM: The aim of this study was to present our experience with video-assisted lumbar sympathectomy for non-reconstructive arterial occlusive disease in a series of 23 consecutive patients whose predominant symptoms were unilateral rest pain, limited skin ulcerations or gangrene of the toes. METHODS: All the procedures were performed with retroperitoneal approach, dorsal position of the patient and simple digital dissection of the retroperitoneal space. RESULTS: The operations were successfully performed in all patients except for 2, who immediately underwent open conversion. A urinoma caused by ureteral lesion was the only severe complication in this series. The mean operative time of the procedure was 55 min and the hospital stay was 2 or 3 days. No parenteral analgesics were administered postoperatively. At 1 month from operation, 20 patients out of 23 had significant relief of rest pain and improvement of ischemic lesions. After a median follow-up of 36 months, 2 patients had died, 4 underwent some type of distal amputation, 1 had recurrent rest pain and the other 16 reported persistent improvement of pain or dystrophic changes. CONCLUSIONS: Retro-peritoneoscopic technique appears the modern and less invasive version of the lumbar surgical sympathectomy.

Aged↗
PubMed2006

[Chemical destruction of sacral nerve roots by alcohol injection for the treatment of overactive bladder].

INTRODUCTION: This study retrospectively reviewed the value of alcohol injection of sacral nerve roots after a lidocaine test in two indications: detrusor instability-detrusor hyperactivity syndrome and cystalgia. MATERIAL AND METHODS: Single-centre retrospective study from January 1992 to March 2003. Twenty-eight patients (1 man, 27 women) were admitted to the urology department for lidocaine test injection because of detrusor hyperactivity 24 cases (idiopathic = 13, neurological = 11), and cystalgia in another 4 cases. RESULTS: After the lidocaine test, infiltration of the sacral nerve roots (bilateral S3) by 70% alcohol was performed in 24/28 cases. The therapeutic effect was assessed at 1 month: 14 out of 24 patients reported that they were globally improved by the alcohol injection. The mean duration of the therapeutic effect was 3.8 months. In the longer term, only one of the 14 patients initially improved did not subsequently experience deterioration of the clinical features (with a follow-up of 8 months). A second alcohol injection was performed in 5/28 patients, with a positive result in only one case (4%). COMPLICATIONS: 6/24 (25%) patients developed lower limb pain that resolved over 2 to 3 months; 3/24 (12%) presented immediate postoperative urinary retention (that persisted in the long term in 1 case); 1/24 (4%) presented cicatricial anal incontinence. CONCLUSION: Alcohol injection of sacral nerve roots is a simple and inexpensive technique, but is associated with morbidity, and has inconstant and only transient effects. It can only be considered exceptionally in highly selected cases when no more effective treatments are available, such as botulinum toxin injection or sacral nerve root neuromodulation.

Adult↗
PubMed1991

[Perineal pain and involvement of the internal pudendal nerves].

A number of chronic pain syndromes in the perineal area can be related to pudental nerves suffering. The constancy of symptoms among various patients, and in duration for a particular one, alterations revealed by electrophysiologic studies, pain relief by diagnostic blocks, data from anatomic studies, preliminary results of medical and surgical applied therapies, give consistent arguments for possible organic lesions of pudental nerves.

Chronic Disease↗
PubMedDate not supplied

[The combined use of acupuncture and antidepressants for managing the spondylogenic lumbosacral pain syndrome].

The effects of antidepressants amitriptyline and pyrazidol on the analgesic action of acupuncture in patients with lumbosacral radiculitis was studied by the double blind control method. The combined use of acupuncture with antidepressants was shown to enhance the effectiveness of the treatment, to increase on the average by 5-6 hours the duration of analgesia within 24 hours after each procedure, to reduce the duration of the treatment on the average by 4-5 days, that indicates the expediency of clinical use of the proposed combination.

Acupuncture Therapy↗
PubMed1991

[Autogenous nerve replantation in situ for prevention and treatment of traumatic neuroma. Laboratory study and clinical application].

The median and ulnar nerves of 30 rabbits were surgically severed and replanted in situ on the right side, but a little segment was resected and left alone on the left side. Periodical examination of the specimen under light and electron microscopes in 24 weeks showed that in the replanted group (right side) the nerve fibers were regularly arranged in order with constant polarity, and the Schwann' cells were intact without signs of neuroma. In the control group (lift side) however, typical neuroma was formed. 30 painful amputation stump neuroma (7 recurrent ones following repeated excisions) in 17 patients were treated by the same method used in the experiment. Follow-up examination within 6-48 months (32.6 mon. on average) showed good and excellent results in 90.0% the neuroma. Four different methods for repairing various neuromas were described, and the cause of the poor result in 2 cases was discussed.

Adult↗
PubMed1991

Dysfunctional uterine bleeding with concomitant low back and lower extremity pain.

In this case presentation, a temporal relationship between conservative chiropractic care and dysfunctional uterine bleeding (DUB) in a patient with mild low back and primary leg pain is described. Criteria are discussed to establish protocol that will be useful in the formulation of a diagnosis for DUB secondary to lower sacral nerve root compression and lumbar mechanical dysfunction. There have been investigations recently published that suggest a positive relationship between chiropractic lumbar, closed reduction distractive decompression (CRDD) and patients with pelvic pain and organic dysfunction. This case study presents the treatment response of one patient with one form of somatovisceral dysfunction, namely, dysfunctional uterine bleeding, in the absence of pelvic pain. Conservative chiropractic care may be an effective, noninvasive method for treating some individuals with dysfunctional uterine bleeding, caused secondarily from biomechanical and/or neurological insult. Further research in this area is encouraged.

Adult↗
PubMed1991

Anatomic consideration for sacral screw placement.

Instrumentation of the lumbosacral spine increasingly involves screw fixation to the sacrum. Recommended locations and techniques for screw placement vary, particularly when bicortical purchase of the sacrum is performed. The purpose of this study was to describe the critical anatomy and potential injuries to neurovascular and visceral structures anterior to the sacrum. Lack of awareness can lead to life-threatening complications. The study included 22 fresh human cadavers with no prior spinal surgery. Specimens were placed in a prone position, and the lumbosacral spine was exposed. Two 6.5-mm screws were inserted using one of two techniques, respectively: Starting just inferior to the S1 facet one screw was angled 25 degrees caudally and 30 degrees laterally; in the second technique, lateral inclination was increased to 45 degrees. In addition, all specimens had screws placed in the S2 pedicles. An anterior dissection was performed to allow evaluation of the neurovascular and visceral structures at risk for injury by, or adjacent to, the screw tips. All significant neurovascular structures in the area of concern were constant in position. The internal iliac vein and the lumbosacral nerve trunk were most at risk for injury by the 30 and 45 degrees laterally directed screws. The sigmoid colon, though close to the S2 screw, was protected by its mesentery. Screws placed in the S1 pedicle were least likely to injure the neurovascular bundle. A lateral and a midline safe zone were identified.

Aged↗
PubMed1991

[Contribution of the CT to a special technique of percutaneous lumbar anesthetic block].

The authors suggest the use of CT for the positioning of a permanent catheter, suitable for lumbar anesthetic block in painful lower limbs syndromes. This technique was employed on 12 patients suffering from vascular diseases of the lower limbs. CT allowed a good visualization of both bone structures and soft tissues, which are essential landmarks for catheter positioning. The catheter was inserted with its anterior end fixed to the anterior abdominal wall, which allowed the patient to manage its own treatment. In all cases we obtained marked symptoms regression, after 5 months of treatment. No such complications were observed as those report in literature. The main contraindication appeared to be the aneurysmatic dilatation of both aorta and iliac arteries.

Female↗
PubMedDate not supplied

A new interabdominis approach to inguinal region block for the management of chronic pain.

The use of an indwelling catheter for repeated injections of local anesthetics has been a beneficial addition to our armamentarium for management of chronic pain syndromes. Indwelling catheters take advantage of anatomic planes, and the concept of an interabdomins muscular plane allows placement of a catheter along the course of the ilioinguinal and iliohypogastric nerves. We report the successful treatment of chronic groin pain via an interabdominis indwelling catheter. This is the first report of the use of such an indwelling catheter.

Abdomen↗