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PubMed1990

The human vertebral column at the end of the embryonic period proper. 4. The sacrococcygeal region.

The sacral and coccygeal vertebrae at 8 postovulatory weeks (the end of the embryonic period proper) have been studied by means of graphic reconstructions. The cartilaginous sacrum is now a definitive unit composed of five separable vertebrae, each of which consists of a future centrum and bilateral neural processes. The base of each neural process consists of an anterolateral or alar element, not present in the lumbar region, and a posterolateral part, which includes costal and transverse elements. The usual illustrations, in which the costal component is placed in the alar element, are incorrect. The future dorsal foramina (containing dorsal rami) face laterally in the embryo and are in line with the thoracicolumbar intervertebral foramina. Considerable differential growth is required to change the dorsal openings from a lateral to a dorsal positions. The intervertebral foramina transmit ventral rami, but pelvic foramina are not yet present. The lumbosacral plexus is completed by S.N.1-3; S.N.4, 5 and Co.N.1 form the pelvic plexus. The inferior hypogastric plexus and the hypogastric nerves are present. The sacrum takes part in the spina bifida occulta that characterises the entire length of the embryonic vertebral column. The coccygeal vertebrae, which are variable, were 4-6 in number in the present series. The first is the best developed. The ventriculus terminalis ends usually at the level of Co.V.1 and the spinal cord generally at Co.V.5. The coccygeal notochord ends commonly in bifurcation or trifurcation. 'Haemal arches' were not observed.

Anthropometry↗
PubMed1980

Variation of the lumbosacral myotomes with bony segmental anomalies.

Clinical localisation of a disc prolapse required dependable knowledge of the muscles supplied by the lumbosacral nerve roots. Localisation is most difficult in the 10 per cent of patients who have lumbosacral bony segmental anomalies. The lumbosacral plexus has been dissected in 11 cadavers with such anomalies and electrical stimulation studies carried out in 15 patients similarly afflicted. It is suggested that whatever the anomaly the "last fully mobile level" should be identified as the lowest level with a fully formed disc space, bilateral facet joints and two free transverse processes which do not articulate with the sacrum or pelvis. In three out of four patients with bony segmental anomalies the fifth lumbar root emerges at the last fully mobile level.

Adult↗
PubMed2006

Magnetic resonance neurography in extraspinal sciatica.

BACKGROUND: Sciatica without evidence of lumbosacral root compression is often attributed to piriformis syndrome. However, specific diagnostic tools have not been available to demonstrate sciatic nerve entrapment by the piriformis muscle. OBJECTIVE: To evaluate the use of magnetic resonance (MR) neurography in identifying abnormalities of the sciatic nerve in patients with unexplained sciatica. DESIGN: Case series from a retrospective medical record review. PATIENTS: Fourteen patients with sciatic distribution pain and normal results on MR imaging for lumbosacral radiculopathy were referred for MR neurography of the lumbosacral plexus and sciatic nerves. RESULTS: In 12 patients, MR neurography demonstrated increased fluid-attenuated inversion recovery signal in the ipsilateral sciatic nerve. In most patients, this abnormal signal was seen at the sciatic notch, at or just inferior to the level of the piriformis muscle. To date, 4 patients have undergone surgical decompression, with excellent relief of symptoms in 3 of them. CONCLUSION: Magnetic resonance neurography often identifies an abnormal increased signal in the proximal sciatic nerve in patients with extraspinal sciatica and allows more accurate diagnosis of sciatic nerve entrapment in suspected cases.

Adult↗
PubMed2004

[Neurological damage in pelvic injuries: a continuous prospective series of 50 pelvic injuries treated with an iliosacral lag screw].

PURPOSE OF THE STUDY: The purpose of this study was to analyze lesions to the lumbosacral plexus related to pelvic injury and its treatment. MATERIAL AND METHODS: Forty-four patients presented 50 posterior osteoligamentary lesions of the pelvic girdle. All patients except eight had other injuries. Mean ISS was 27/75. Posterior lesions were: iliosacral disjunction (n=23), extra-foraminal fracture of the sacrum (n=4), transforaminal fracture (n=22), intra-foraminal fracture (n=1). Vertical posterior displacement was > 1 cm for 24 posterior lesions. Orthopedic reduction was performed at admission for all patients. Fluoroscopy-guided percutaneous lag screw fixation was performed in all cases, on the average eight days after the accident. Neurological involvement was evaluated at admission, after surgery, and at last follow-up. Data were recorded for skeletal muscles, lower limb dermatomes, tendon reflexes, and anal tone. Screw emplacement was checked on the CT-scan. Outcome was assessed subjectively with the Majeed score, a self-administered visual analog scale, and use of antalgesic drugs according to the WHO classification. RESULTS: The neurological examination could not be performed for ten patients at admission. Postoperatively, there was a neurological deficit associated with 26 osteoligamentary lesions (23 lesions of the lumbosacral trunk, 14 lesions of the S1 spinal nerve, 3 lesions of the pudendal nerve, 12 lesions of the superior gluteal nerve, and 10 lesions of the femoral nerve). Patients with neurological involvement had experienced more severe trauma. The iliosacral screw was partially extra-osseous in thirteen cases, with an associated iatrogenic neurological deficit in seven. At mean follow-up of 20 Months (range 4-50) there persisted ten major sequelae including eight cases of hallux extensor deficit. DISCUSSION: Neurological involvement is underestimated during the acute phase of trauma. After recovery, only the manifestations of major injuries persist. The prognosis is poor in the event of a stretched lumbosacral trunk or gluteal nerve due to iliosacral disjunction. Prognosis is good for nerve contusion due to sacral fracture because of early reduction. The femoral nerve is generally injured by compression due to a peri-fracture hematoma; recovery is the rule. Iliosacral screwing requires rigorous technique by a skilled and experienced surgeon. CONCLUSION: About 52% of posterior osteoligamentary injuries are associated with neurological symptoms. After recovery, permanent deficit persists in 21.7%. The most common sequelae are hallux extensor and gluteus medius palsy due to stretching of the lumbosacral trunk.

Adolescent↗
PubMed2005

Multiple perineuriomas in chicken (Gallus gallus domesticus).

Intraneural perineurioma is an extremely rare condition characterized by perineurial cell proliferation within peripheral nerve (PN) sheaths. In the veterinary field, this entity has been reported only in a dog. We examined multiple enlargements of PNs in 11 chickens (Gallus gallus domesticus) (9 Japanese bantams and 2 specific pathogen-free White Leghorn), which were inoculated with an avian leukosis virus (ALV) causing so-called fowl glioma. All chickens clinically exhibited progressive leg paralysis. Lumbosacral plexus, brachial plexus, and/or spinal ganglion were commonly affected, and these nerves contained a diffuse proliferation of spindle cells arranged concentrically in characteristic onion bulb-like structures surrounded by residual axons and myelin sheaths. The spindle cells were immunohistochemically negative for S-100alpha/beta protein. Electron microscopy revealed that these cells were characterized by short bipolar cytoplasmic processes, occasional cytoplasmic pinocytotic vesicles, and discontinuous basal laminae. These features are consistent with those of intraneural perineurioma. Furthermore, the specific sequence of the ALV was detected in the PN lesions of 8/11 (73%) birds by polymerase chain reaction. These results indicate that the multiple intraneural perineuriomas of chicken may be associated with the ALV-A causing fowl glioma.

Animals↗
PubMed1994

[Antalgic radiotherapy in lumbosacral carcinomatous neuropathies].

Lumbosacral carcinomatous neuropathy (LCN) may be caused by infiltration or compression of the lumbosacral plexi and nerves from intrapelvic or paraaortic neoplasms. The authors submitted 23 patients complaining of LCN with CT documented intrapelvic or paraaortic tumors to palliative radiotherapy. Megavoltage external beam irradiation was administered using a 6-MV linear accelerator. Treatment field sizes ranged from 56 cm2 to 235 cm2 (mean: 150.54 cm2) and encompassed only the site where the disease involved the lumbosacral plexus or its branches. > or = 3 Gy/day fractions were used. Twenty-one of 22 assessable patients (95.4%) obtained LCN pain relief; 19 (86.3%) obtained complete LCN pain relief. The median time to pain progression (TPP) was 150 days (range: 39-510 days). The median survival was 165 days. Seven patients were LCN pain-free at death. Two patients are alive and LCN pain-free. The remaining 12 patients had recurrent LCN pain: four of them were reirradiated at the site of previous neuropathy and only two had partial relief again. The authors conclude that it is advisable to submit to palliative radiotherapy the inoperable disseminated and/or recurrent cancer patients complaining of LCN, to use large fractions not to occupy the extant time of their already short life-expectancy, and to design small fields to avoid acute side-effects.

Adult↗
PubMed1979

The morphogenesis of the thigh of the mouse with special reference to tetrapod muscle homologies.

In order to provide an ontogenetic basis for the establishment of tetrapod muscle homologies and for the analysis of complex mammalian muscle states, a descriptive analysis of the morphogenesis of the thigh of Mus musculus has been made. The pattern and sequence of muscle cleavage and the migrations of individual muscle primordia are characterized from the eleventh day of gestation, when cleavage begins, through early neonatal stages. Observations on skeletal differentiation and lumbosacral plexus formation are also included. Thigh muscle morphogenesis is compared to that in the lizard, Lacerta, (Romer, '42) and the chick (Romer, '27) and homologies identified. An onogenetic basis for the definition of ancestral and derived muscle states is provided in muscles that are morphologically variable in mammals. These include the gluteus minimus, gracilis, adductor brevis and several hamstring muscles. Certain muscles that show variable innervation patterns in adult mammals, i.e., pectineus, quadratus and adductor magnus, typically develop from premuscle regions that separate muscle anlagen innervated by different nerves. Two muscle anlagen appear in the embryonic mouse thigh and then disappear late in prenatal or early postnatal development. Comparisons with other mammals, especially the marsupial, Marmosa, reveal that these muscles are phylogenetic vestiges that degenerate before maturity. A sartorius vestige is identifiable through the thirteenth day of gestation. A tenuissimus anlage is present until shortly after birth and is clearly innervated by a branch of the peroneal nerve.

Animals↗
PubMed2001

Non-diabetic lumbosacral radiculoplexus neuropathy: natural history, outcome and comparison with the diabetic variety.

Diabetic lumbosacral radiculoplexus neuropathy (DLSRPN) (other names include diabetic amyotrophy) is well recognized, unlike the non-diabetic lumbosacral radiculoplexus neuropathy (LSRPN), which has received less attention. Our objective was to characterize the natural history and outcome of LSRPN and to assess whether it is similar to the diabetic variety in its symptoms, course, electrophysiological features, quantitative sensory and autonomic findings, and the underlying pathophysiology. We studied 57 patients with LSRPN and 33 patients with DLSRPN. We found that the age of onset, course, kind and distribution of symptoms and impairments, laboratory findings and outcomes are essentially alike. Both disorders are a lumbosacral plexus neuropathy associated with weight loss, often beginning focally or asymmetrically in the thigh or leg but usually progressing to involve the initially unaffected segment and the contralateral side. Both have prolonged morbidity due to pain, paralysis, autonomic involvement and sensory loss. In biopsied distal LSRPN nerves, we found changes similar to those found in DLSRPN-alterations typical of ischaemic injury and of microvasculitis. The long-term outcome was determined in 42 LSRPN patients: two had become diabetic, seven had relapsed and only three had recovered completely, although all had improved. We conclude that: (i) LSRPN is a subacute, asymmetrical, painful and debilitating neuropathy of the lower limbs associated with weight loss, and we think it is under-recognized; (ii) recovery from the long-term impairments of LSRPN is usually delayed and incomplete and only a small minority of patients develop diabetes mellitus; (iii) LSRPN mirrors the diabetic variety in its clinical features, course, pathological findings (ischaemic injury from microvasculitis) and long-term outcome; and (iv) LSRPN should be set apart from chronic inflammatory demyelinating polyradiculoneuropathy and from systemic necrotizing vasculitis. We infer an autoimmune basis for LSRPN and emphasize the need for controlled trials of immune-modulating therapy.

Adult↗
PubMed1987

Maintenance of specificity by sprouting and regenerating peripheral nerves. II. Variability after lesions.

In previous studies we showed that collateral sprouting in cat tibialis anterior (TA) muscle was elicited by selective peripheral spinal nerve section sparing L7. After chronic (3 week) section of L5, L6, S1 and S2 spinal nerves in the present study, two different reflex patterns were observed. In some cats, with presumed prefixation of the lumbosacral plexus, the TA tendon reflex was weakened initially and became stronger beginning 2-3 days postoperative. In other cats, with presumed postfixation of the plexus, the TA tendon reflex was abolished for 7-9 days and then returned. The TA muscles were injected with HRP and labeled motor neurons plotted. In the 'prefixed' first group, the number, location and size of motor neurons projecting to TA through the spared L7 nerve were symmetrical when acute and chronic sides were compared. In the 'postfixed' group (reflex abolished then returned) the acute and chronic sides were asymmetrical: the chronic side displayed a significant increase in number of labeled cells and an increase in the rostocaudal extent of the cell column within the L7 segment. These results are consistent with two types of collateral sprouting: homonymous, in which the sprouts arise from nerves within the muscle, and heteronymous, in which the sprouts arise from nerves in adjacent muscles. In animals with very chronic (up to 2 years) spinal nerve section (L5, L6, S1 and S2) regeneration of the cut nerves was superimposed on the spared L7 innervation. Topography was completely disrupted except in the L7 segment. Thus, there appears to be a difference in specificity of motor neurons for target sites depending upon degree and location of denervation. Homonymous sprouting displays strict specificity, regeneration does not and heteronymous sprouting represents an intermediate form in which cells are recruited from adjacent motor neuron pools in the segment of the spared innervation.

Animals↗
PubMed1984

Projections of hindlimb dorsal roots to lumbosacral spinal cord of cat.

Single dorsal roots of spinal nerves that contribute to the cat lumbosacral plexus (L3-S2) were cut to evoke degeneration of centrally projecting axons. Serial sections throughout lumbosacral cord levels were impregnated by the Fink-Heimer method (20) to permit charting of the distribution patterns of segmental dorsal root afferent fibers. Afferent fibers that enter a single dorsal root have an extensive distribution to multiple cord segments; their longitudinal extent varies with entry level and with laminar targets. Afferent projections to the ventral horn reach motor nuclei only in their entry segment and the adjacent segments just above and below their entry. Those afferent fibers projecting to intermediate gray (laminae VI and VII) have the most extensive spinal distribution of any types; they may, from a single dorsal root, reach as many as 13 or 14 cord segments. Dorsal horn projections of single roots are also longitudinally expansive. Small-diameter afferent fibers course rostrally and caudally in Lissauer's tract (LT) for up to 9-10 segments. They appear to terminate in at least laminae I and II in and near their entry segment; their endings are difficult to demonstrate at greater distances where they are probably less dense. Larger caliber axons entering the dorsal horn generate a somatotopically organized projection, especially to laminae III and IV. Collaterals of these fibers appear to course longitudinally within the gray matter and they distribute to as many as six to seven segments.

Animals↗
PubMed1999

Complications during anterior surgery of the lumbar spine: an anatomically based study and review.

Procedures involving anterior surgical decompression and fusion are being performed with increasing frequency for the treatment of a variety of pathological processes of the spine including trauma, deformity, infection, degenerative disease, failed-back syndrome, discogenic pain, metastases, and primary spinal neoplasms. Because these operations involve anatomy that is often unfamiliar to many neurological and orthopedic surgeons, a significant proportion of the associated complications are not related to the actual decompressive or fusion procedure but instead to the actual exposure itself. To understand the nature of these injuries, a detailed anatomical study and dissection was undertaken in six cadaveric specimens. Critical structures at risk in the abdomen and retroperitoneum were identified, and their anatomical relationships were categorized and photographed. These structures included the psoas muscle, kidneys, ureters, diaphragm and crura, esophageal hiatus, thoracic duct, greater splanchnic nerves, phrenic nerves, sympathetic chains, medial arcuate ligament, superior and inferior hypogastric plexus, segmental and radicular vertebral vessels, aorta, vena cava, median sacral artery, common iliac vessels, iliolumbar veins, lumbosacral plexus, and presacral hypogastric plexus. Based on these dissections and an extensive review of the literature, the authors provide a detailed anatomically based discussion of the complications associated with anterior lumbar surgery.

Journal Article↗
PubMed1998

[Pain in one leg in patients with cancer].

Two patients, a woman aged 65 years and a man aged 56 years, with cancer, presented with pain in one leg as the first manifestation of metastases. The woman had tumour plexopathy of the lumbosacral plexus caused by an os sacrum metastasis of a thyroid carcinoma; she received radiotherapy but died a short time later. The man had lumbosacral epidural metastases of a colon carcinoma, compressing lumbosacral roots; with radiotherapy he survived the first year. Back pain with radiating pain is a frequent symptom in patients with cancer. Spinal epidural metastases, spinal and paraspinal metastases without epidural extension, tumour plexopathy and leptomeningeal metastases are the commonest causes. Early diagnosis (by MRI or spinal fluid examination) is important; with progressive weakness or sphincter disturbances the prognosis worsens.

Aged↗
PubMed2000

Peripheral nerve repairs and their results in children.

It seems that lesions of nerves in children account for 10% to 15% of the total cases seen in this, as in other, specialist units. The prognosis for recovery after repair is defined by the severity of the original injury. The authors' worst results were seen in complete lesions of the supraclavicular brachial plexus and in the untidy wounds of war, in which penetrating missiles destroyed the proximal femur and the adjacent nerves. The outcome for injuries to the lumbosacral plexus, from fractures of the pelvis or from penetrating missile injury, are as bad. The most significant variable in determining prognosis is delay. Evidently, children are at least as vulnerable to the harmfulness of this as are adults. Skillful primary repair, however, is often followed by recovery to near normal levels, even in complex cases. Adequate follow-up is essential to detect and treat progressive deformity, especially at the ankle and foot.

Child↗
PubMed1988

[Plexus lesions, rhabdomyolysis and heroin].

Of five patients admitted to hospital after heroin injection, three had injected heroin exclusively, and two had taken several other drugs orally in addition to heroin. All patients developed severe rhabdomyolysis as well as lesions of the brachial or lumbosacral plexus or both, affecting more than one extremity in three cases. The neurologic symptomatology occurred with variable latency after heroin injection. Additionally, one patient presented a bilateral compartment syndrome in the lower extremities. While CK values normalized within 2-3 weeks, even severe pareses markedly improved within only a few months. Current knowledge of these complications is summarized from the literature and several pathophysiological hypotheses are derived from the present case histories. In the light of theoretical considerations and our own observations of comparable clinical features in patients who had not consumed opiates, the question arises whether the syndrome is heroin specific or not.

Adolescent↗
PubMed2002

Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation.

UNLABELLED: A computed tomographic scan was obtained in 35 patients to measure the depth and the relationship of the branches of the lumbar plexus to the posterior superior iliac spine projection and the vertebral column. In addition, we prospectively studied 80 patients scheduled for total hip arthroplasty who received a continuous psoas compartment block (CPCB) in the postoperative period. CPCB was performed after surgical procedures by using modified Winnie's landmarks and nerve stimulation. From 5 to 8 cm of catheter was inserted. Radiographs were obtained after injection of 10 mL of contrast medium. An initial loading dose (0.4 mL/kg) of 0.2% ropivacaine was injected, followed by continuous infusion of 0.2% ropivacaine for 48 h. The depth of the lumbar plexus and the distance between the lumbar plexus and the L4 transverse process were measured. Visual analog scale values of pain at 1, 12, 24, and 48 h were obtained at rest and during mobilization. Amounts of rescue analgesia were also recorded. Sensory blockade of the principal branches of the lumbosacral plexus was noted at 1 and 24 h, as were adverse events related to the technique. There was a significant difference between men and women in depth of the lumbar plexus (median values, 85 vs 70 mm for men and women, respectively). There was a positive correlation between the body mass index and skin-lumbar plexus distances. In contrast, there was no difference regarding the distance between the transverse process of L4 and the lumbar plexus. The catheter tip lay within the psoas major muscle in 74% of the patients and between the psoas and quadratus lumborum muscles in 22%. In three patients, the catheter was improperly positioned. At 1 h, sensory blockade of the femoral, obturator, and lateral femoral cutaneous nerves was successful in, respectively, 95%, 90%, and 85% of patients. At 24 h, these rates were 88%, 88%, and 83%, respectively. During the 48-h study period, median visual analog scale values of pain were approximately 10 mm at rest and from 18 to 25 mm during physiotherapy. Five patients received 5 mg of morphine at 1 h. Five cases of unilateral epidural anesthesia were noted after the bolus injection. We conclude that CPCB with 0.2% ropivacaine allows optimal analgesia after hip arthroplasty, with few side effects and a small failure rate. Before lumbar plexus branch stimulation and catheter insertion, anesthesiologists should be aware of the L4 transverse process location and lumbar plexus depth. IMPLICATIONS: Lumbar plexus depth is correlated with the patient's body mass index and differs between men and women, but this is not true of the lumbar plexus-transverse process distance. Considering new landmarks, a continuous psoas compartment block promotes optimal analgesia after hip arthroplasty, with few side effects.

Adult↗
PubMed1999

c-Fos expression in the myenteric plexus, spinal cord and brainstem following injection of formalin in the rat colonic wall.

Fos expression induced by injection of dilute formalin (50 microl, 5% in physiological saline) into the colonic wall was examined in the myenteric plexus, lumbosacral spinal cord and brainstem of the rat. The aims of this study were (i) to determine whether neurons in these regions express Fos in response to the injection of formalin into the colon and (ii) to examine whether administration of an alpha 2 adrenoceptor agonist modulates Fos expression. Tissues were removed 2 h after the injection of saline or formalin. Saline injected in the colon induced Fos in enteric glia in the myenteric plexus. The number of Fos immunoreactive nuclei significantly increased in both myenteric neurons and enteric glia after the injection of formalin. Similarly, Fos immunoreactive neuronal nuclei were significantly increased in the spinal cord, area postrema and nucleus of the solitary tract after the injection of formalin. Pretreatment of rats with the alpha 2 adrenoceptor agonist xylazine (2, 4 and 8 mg/kg) 15 min before the injection of formalin, dose-dependently reduced the number of Fos immunoreactive neuronal and glial nuclei in the myenteric plexus, and neuronal nuclei in the spinal cord and brainstem. Simultaneous administration of xylazine (8 mg/kg) and the alpha 2 adrenoceptor antagonist yohimbine (1 mg/kg) reversed the effects of xylazine in the spinal cord and brainstem, but not in the myenteric plexus. These data show that injection of formalin in the colonic wall results in Fos expression in myenteric neurons and enteric glia, and neurons in the spinal cord and brainstem. This may be due to the direct chemical stimulation of the innervation of the colon and/or the subsequent acute colitis. The observed neuronal Fos expression can be modulated by an alpha 2 adrenoceptor agonist through noradrenergic pathways and/or reduction of the excitability of the enteric neural circuitry.

Adrenergic alpha-Agonists↗