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Lumbosacral plexus lesions developed in two women 8 and 14 years, respectively, after operation and irradiation for carcinoma of the uterus. In both patients, a left femoral nerve lesion was the presenting sign. The irradiation dose was about 5,000 rad on both sides in patient 1 and 8,400 rad on the affected side in patient 2. Both patients had low-frequency periodic discharges in the EMG.
Primary lumbosacral plexus neuropathy without underlying disease is a well-defined syndrome characterized by pain, weakness, and atrophy in the distribution of the lumbosacral plexus. It generally affects adults and rarely occurs in children. We report 2 children with primary lumbosacral plexus neuropathy evaluated at our institution and review the literature. This syndrome, despite initially severe symptoms, appears to be benign with a favorable prognosis in children.
Carcinomatous lumbosacral plexus neuropathy is a relatively rare occurrence, although it is frequently encountered in clinical oncologic practice. The value of radiotherapy for this neoplastic disease complication was assessed in 28 evaluable patients from two institutions between 1981 and 1984. In over half of the cases, the subjects were 40 to 60 years old and had carcinoma of the ano-rectosigmoid colon. The overall therapeutic subjective and objective response rates were 88.8 and 48.1%, respectively. The complete subjective response rate was 85.1% whereas the complete objective response rate was only 29.6%. From an evaluation of the various total dosage schedules employed, it appeared that a favorable (subjective/objective) treatment result was dependent upon a higher administered total dose of no less than 30 Gy.
The lumbosacral plexus was dissected bilaterally in 20 adult cadavers to define the anatomic relationship of the lumbosacral plexus to the sacrum and the sacroiliac joint. All results are mean values +/- standard deviation. The length of the nerve roots of the lumbosacral plexus gradually decreased from L-4 to S-3 (from 93.8 +/- 6.9 mm in males and 108.7 +/- 7.7 mm in females at L-4 to 43.7 +/- 4.3 mm in males and 49.0 +/- 7.6 mm in females at S-3). The angle projected by the nerve roots of the lumbosacral plexus with respect to the sagittal plane gradually increased from L-4 to S-3 (from 14.3 degrees +/- 3.4 degrees in males and 16.7 degrees +/- 4.8 degrees in females at L-4 to 51.8 degrees +/- 9.0 degrees in males and 57.8 degrees +/- 9.1 degrees in females at S-3). The width of the nerve roots of the lumbosacral plexus was greatest at S-1 (9.8 +/- 1.8 mm in males, 8.6 +/- 1.5 mm in females). The L-5 nerve root was the thickest in males (4.4 +/- 0.5 mm), and the S-1 nerve root was thickest in females (4.3 +/- 0.4 mm). The lumbosacral trunk was 30.0 +/- 9.0 mm in length in males and 32.0 +/- 6.0 mm in females; 11.4 +/- 1.8 mm wide in males and 11.2 +/- 1.5 mm in females; and 4.4 +/- 0.5 mm thick in males and 4.0 +/- 0.6 mm in females. The fifth lumbar nerve root and lumbosacral trunk coursed across the sacroiliac at a level 2.0 +/- 0.2 cm below the pelvic brim and were relatively fixed to the sacral ala with fibrous connective tissue.
Primary lumbosacral plexus neuropathy (LSPN) is a well-defined syndrome characterized by pain, weakness and atrophy in the distribution of the lumbosacral plexus. Previous reports of LSPN have stressed the benign nature of the syndrome. Patients generally have a nearly complete recovery in months to years following the initial event. Two patients presenting with a relapsing form of LSPN are reported. The diagnosis of LSPN was based on clinical and electromyographic features, and no underlying cause was found on initial evaluation or subsequent follow-up over a 6- to 8-year period. We suggest that these patients represent a clinically and possibly pathologically distinct subgroup of LSPN.
Injuries to the lumbosacral plexus during labor and delivery have been reported in the literature for years, but have lacked electrophysiologic testing to substantiate the location of the nerve injury. We report 2 cases with comprehensive electrophysiologic testing which localizes the site of this obstetrical paralysis to the lumbosacral trunk (L4-5) and S-1 root where they join and pass over the pelvic rim. The paralysis may be mild or severe. Small maternal size, a large fetus, midforceps rotation, and fetal malposition may place the mother at risk for this nerve injury.
Lumbosacral plexus block is a valuable anesthetic technic in the hands of an experineced anesthesiologist. However, as illustrated by this case report, anesthetic dosage must be selected with great care, and patients unable to describe paresthesias should be excluded from use of this procedure.
OBJECT: The purpose of this study was to analyze therapeutic possibilities and clinical outcomes in patients with lumbosacral plexus injuries to develop surgical concepts of treatment. METHODS: In a retrospective investigation 10 patients with injuries to the lumbosacral plexus were evaluated after surgery. The patients were assessed clinically, electrophysiologically, and based on the results of magnetic resonance imaging and computerized tomography myelography. In most patients a traction injury had occurred due to severe trauma that also caused pelvic fractures. In most cases the roots of the cauda equina of the lumbosacral plexus had ruptured. In cases of spinal root ruptures repair with nerve grafts were performed. In cases in which proximal stumps of the plexus could not be retrieved palliative nerve transfers by using lower intercostals nerves or fascicles from the femoral nerve were performed. CONCLUSIONS: Lesions of the proximal spinal nerves and cauda equina occur in the most serious lumbosacral plexus injuries. Patients with such injuries subjected to reconstruction of spinal nerves, repair of ventral roots in the cauda equina, and nerve transfers recovered basic lower-extremity functions such as unsupported standing and walking.
A metastatic multicentric neurofibrosarcoma of the lumbosacral plexus in an adult cow is described. The left lumbosacral plexus was obliterated by a mass which extended through the intervertebral foramen into the spinal canal and between the dorsal arches of the fifth and sixth lumbar vertebrae. A closely associated (possibly contiguous) mass extended into and separated the left sacroiliac joint. Multiple similar masses involved peripheral nerves and skeletal muscles of the pelvis, pelvic limbs, and abdominal wall. Metastatic lesions were scattered throughout the lungs. The lumbosacral lesion and all other masses consisted of interwoven bundles of loosely cohesive, elongated cells separated by variable collagenous matrix. Many neoplastic cells were positive for S-100 protein. Ultrastructurally, fibroblastic cells were mixed with scattered cells possessing schwannian characteristics.
Lumbosacral plexus neuropathy (LSPN) is an idiopathic clinical syndrome characterized by the sudden onset of neuropathic pain, followed by weakness and sometimes sensory disturbances in the distribution of the lumbosacral plexus. Prognosis is usually favourable, although complete recovery may take several months to years. LSPN is the lumbosacral counterpart of the neuralgic amyotrophy syndrome (idiopathic brachial plexus neuropathy). We present a patient who initially was misdiagnosed with a radicular syndrome, but illustrates the typical signs and symptoms of LSPN. We also give clinical and electromyographical criteria for the diagnosis of LSPN and review the literature.
In 53 cases of injury of the lumbosacral plexus, 31 were due to trauma and 22 followed operations on the hip joint. Post-traumatic lesions occur mostly in conjunction with severe bony injuries, especially fractures of the acetabulum and of the pelvic ring. Nearly always, it is the sacral portion of the plexus that is involved, either predominantly or exclusively. Seventeen of the 22 postoperative pareses followed complete hip-joint replacement. In the postoperative lesions the lumbar plexus portion is most frequently involved. Ninety-one percent of all of our cases were misdiagnosed in previous clinical examinations, that is, as a lesion of the femoral or sciatic nerve, or they were unrecognized because of lack of awareness of the possibility of plexus damage or because the signs were obscured by the associated bony injuries or hip-joint disease. In order to make an exact diagnosis, a detailed electromyographic investigation is necessary.
Two hundred and forty histological paraffin sections were obtained from the midportion of the spinal nerve roots of 20 lumbosacral plexus (from L4 to S3) bilaterally. All microscopic images were digitized using the NIH image software with a Nikon microscope and Sony videocamera. The total, fascicular as well as epineurial cross-sectional areas of the nerve roots in the lumbosacral plexus were determined. The total cross-sectional area of the lumbosacral trunk (LST) was the largest (28.56 +/- 12.28 mm2) followed by the S1 (21.97 +/- 11.22 mm2) and L5 (21.00 +/- 8.79 mm2) nerve roots. The total cross-sectional areas of the L4 (6.93 +/- 3.32 mm2), S2 (13.93 +/- 5.86 mm2) and S3 (6.03 +/- 3.74 mm2) were significantly lower. Statistical differences were found among all absolute values at different levels (p < 0.0001) with the exception of the levels between L4 and S3, L5 and S1, and LST and S1 (p > 0.05). The total areas occupied by the fascicles in L5 (7.78 +/- 3.26 mm2), LST (9.97 +/- 4.01 mm2) and S1 (8.55 +/- 3.27 mm2) nerve roots were greater than those in L4 (2.96 +/- 1.50 mm2), S2 (5.56 +/- 2.34 mm2) and S3 (2.28 +/- 1.14 mm2). However, the percentages of the total cross-sectional areas occupied by the fascicles in the L5 nerve root (38%) and LST (36.4%) were smaller compared to other nerve roots (44.9% at L4, 40.5% at S1, 40.8% at S2 and 41.6% at S3). The cross-sectional areas and percentages of the epineurium were greater in L5 (13.22 +/- 6.48 mm2, 62.0%), LST (18.58 +/- 9.31 mm2, 63.6%) and S1 (13.42 +/- 8.88 mm2, 59.5%) roots. The L5 (12.1 +/- 5.0), LST (27.5 +/- 11.4) and S1 (15.0 +/- 7.3) roots contained more fascicles than L4 (6.3 +/- 3.3), S2 (9.5 +/- 4.1) and S3 (7.1 +/- 2.7). Statistical differences were found among all absolute values at different levels (p < 0.0001) with the exception of the levels between L4 and S3, L5 and S1 and LST and S1 (p > 0.05). No statistical differences were found for percentages among different levels (p > 0.05) with the exception of the levels between L4 and L5, L4 and LST, LST and S1, LST and S2, and LST and S3 (p < or = 0.05). The histological structure of nerve roots of the lumbosacral plexus is identical to that of the peripheral nerve. The midportions of L5 and S1 roots and the LST have a relatively higher epineurial content. These nerve roots also have a greater number of the fasicles, but the total cross-sectional area occupied by the fascicles is less than in L4, S2 and S3 nerve roots.
We describe 10 cases of lumbosacral plexus neuropathy in which no underlying condition was discovered on initial evaluation or on follow-up examination after an average of 6 years. The patients presented with pain and weakness. Recovery was delayed and often incomplete. When the lower plexus is involved, it may be confused with disk disease manifesting as "sciatica." This syndrome may be a counterpart to the well-described idiopathic brachial plexus neuropathy.
The distinct clinical syndrome of exercise induced ischaemia of the lumbosacral plexus is not a widely known cause for intermittent claudication. Eight patients with the mentioned syndrome were investigated clinically, neurophysiologically, and with imaging techniques. The clinical examination showed a typical exercise induced sequence of symptoms: pain, paraesthesia, and sensory and motor deficits. The underlying vascular conditions were high grade stenoses or occlusions of the arteries supplying the lumbosacral plexus. Spinal stenosis could be excluded in all cases. Five patients received successful interventional radiological therapy. The syndrome can be diagnosed clinically and successful therapy is possible by interventional radiology.
Lumbosacral plexus or external iliac artery injuries associated with pelvic fracture are reported rarely in the literature. A case involving a noncompound open book pelvic injury with diastasis of the symphysis pubis and combined ipsilateral lumbosacral plexus and external iliac artery injury is reported. Repeated clinical examination to diagnose vascular lesions with evolving pulse deficits is emphasized.
Before high resolution computed tomography (CT), the lumbosacral plexus was nearly impossible to image. While individual elements of the plexus are not consistently resolved using CT, the regional anatomy is reproducible and allows accurate evaluation. Normal regional anatomy was established by axial cadaver dissection and review of 233 normal computed tomographic examinations. This regional anatomy has been presented in detail. In addition, 17 patients with lumbosacral plexopathy due to benign, neoplastic and idiopathic causes were imaged. Our results show that CT is effective in the evaluation of suspected structural lesions of the lumbosacral plexus.
The lumbosacral plexus of the Japanese serow was grossly investigated on 30 fresh specimens. 28 of 30 showed 6 lumbar vertebrae and 2 of the remaining had 5. The communicating pattern among segmental origins from L3 to S5 revealed a variability of the plexus in both types of 5 and 6 lumbar vertebrae. The ratio of prefixed, median fixed and postfixed plexuses in 6 lumbar vertebral type was nearly 2:6:1. The serow's plexus was basically similar to that of domestic ruminants.
A case is reported of a lumbosacral plexus compression by the fetus in a young 34-weeks pregnant woman, who had low-back pain and progressive muscular weakness of the leg. Neurological examination showed a grade IV motor weakness of the iliopsoas, quadriceps femoris and biceps femoris muscles. Mechanical stretch manoeuvers were negative. Electromyography revealed denervation activity in L4 and L5 muscles. Lumbosacral plexus radiculopathy was diagnosed. Although fetal compression appears to be an uncommon cause of lumbosacral radiculopathy during teenage pregnancy, both neurosurgeons and obstetricians should be aware of the possibility.