Safety and efficacy of laparoscopic distal rectal transection by transanterior obturator nerve gateway / 中华胃肠外科杂志

Objective: To evaluate the safety and efficacy of distal rectal transection by using transanterior obturator nerve gateway (TANG) in laparoscopic radical resection for lower rectal cancers. Methods: A descriptive case series study was performed. Inclusion criteria: (1) patients with primary rectal adenocarcinoma, with the distance of 3-5 cm from tumor to anal verge, with normal anal function before surgery and a desire to preserve anus; (2) laparoscopic radical resection of rectal cancer was performed and the distal rectum was transected using TANG approach. Exclusion criteria: (1) patients with distant metastasis or receiving palliative surgery; (2) the distal rectum was transected using non-TANG approach; (3) patients receiving combined multiple organs resection; (4) patients complicated with other tumors requiring additional treatment during the study. Clinicopathological data of 50 patients with low rectal cancer undergoing laparoscopic resection using TANG approach between January 2019 and December 2020 in Peking University First Hospital were retrospectively collected. Perioperative conditions, length of specific pelvic lines, additional angle and postoperative short-term outcomes were observed and described. Additional angle was defined as the angle between the simulated stapling line with the traditional approach and the real stapling line with the TANG approach. Data following normal distribution were presented as Mean±SD, or M [quartile range (Q(R))] otherwise. Results: All the patients successfully completed laparoscopic surgery without transferring to open or transanal surgery. The median operative time was 193 (80) min and blood loss was 50 (58) ml. All tumors received R0 resection with the distance from the tumor to distal resection margin of 1.7 (0.4) cm and the anastomotic height of 2.0 (0.1) cm. Rectal transection was completed by one cartridge in 52.0% of the cases (26/50) and two cartridges in 48.0% (24/50). Length of the stapling line was 6.6 (1.5) cm. The time to construct the gateway was 8.0 (6.0) min. The vessel damage occurred in 4.0% of the cases (2/50) and none of the cases encountered obturator nerve damage. Inlets of the pelvis in TANG and traditional approach were (9.9±1.3) cm vs. (7.2±1.1) cm (t=24.781, P<0.001). Additional angle of TANG was (15±2) °. The transecting positions on the midline and right edge of the rectum specimen by TANG were 0.6 (0.2) cm and 1.0 (0.2) cm lower than those by the traditional approach. One case (2.0%) died of pulmonary infection on the 17th day after surgery, 2 cases (4.0%) received re-operation and 14 cases (28.0%) had postoperative complications, including anastomotic leakage (7/50, 14.0%), urinary retention (6/50, 12.0%), pelvic infection (2/50, 4.0%) and ileus (2/50, 4.0%). The median postoperative hospital stay was 12 (6) days. Conclusions: Laparoscopic distal rectal transection by using TANG approach is safe and effective in the treatment of low rectal cancer. As an alternative rectal transecting method, TANG has advantages especially for the obese and those with a contracted pelvis and ultralow rectal cancers.

Monopolar versus bipolar transurethral resection of lateral wall-located bladder cancer under obturator nerve block: a single center prospective randomized study

ABSTRACT Introduction: The aim of the present prospective-randomized study was to compare perioperative outcomes and complications of bipolar and monopolar TURBT for lateral wall-located non-muscle invasive bladder cancers (NMIBC) under obturator nerve block (ONB). Patients and Methods: 80 patients who underwent TURBT for lateral wall-located primary bladder tumors under ONB from March, 2016 to November, 2019 were included in the present study. The patients were randomized equally into two groups; monopolar TUR (M-TURBT) and bipolar TUR (B-TURBT). The primary and secondary outcomes were safety (obturator jerk and bladder perforation) and efficacy (complete tumor resection and sampling of the deep muscle tissue). Results: Obturator jerk was detected in 2 patients (5%) in M-TURBT while obturator jerk was not observed during B-TURBT (p=0.494). Bladder perforation was not observed in both groups. All of the patients underwent complete tumor resection. There was no significant difference in muscle tissue sampling (67.5% vs. 72.5%, p=0.626) and thermal tissue damage rates (12.5% vs. 25%, p=0.201). The majority of complications were low-grade and the differences in Clavien grade 1-3 complications between groups were not statistically significant. Conclusion: In the treatment of lateral-wall located NMIBCs, either M-TURBT or B-TURBT can be safely and effectively performed by combining spinal anesthesia with ONB. Even so, it should be taken into consideration that low-grade postoperative hemorrhagic complications may occur in patients who undergo M-TURBT.

Schwannoma anciano del nervio obturador: una rara causa de neuralgia / Ancient schwannoma of the obturator nerve: an uncommon cause of pelvic neuralgia

Los tumores retroperitoneales son lesiones infrecuentes. Las tumoraciones nerviosas benignas como los schwannomas representan menos del 3% de ellos, siendo extremadamente raros los que afectan el nervio obturador. Presentamos el caso de un paciente con importante afectación funcional en miembro inferior izquierdo y dolor pélvico, al que se le diagnosticó neoplasia retroperitoneal. Fue intervenido por vía laparoscópica objetivándose la dependencia de la lesión del nervio obturador. Se llevó a cabo una exéresis completa de la lesión preservando parcialmente el nervio. El paciente tuvo una evolución funcional y álgica muy favorable. La anatomía patología reveló la presencia de schwannoma, del denominado subtipo "anciano", sin datos de malignidad. Consideramos que el informe de un caso como este puede ayudar a conocer una patología muy infrecuente y a tener en consideración algunos puntos clave como la técnica de abordaje y la necesidad de preservación de las estructuras nerviosas.

Retroperitoneal tumors are uncommon; benign tumors originating in the nerve cells as schwannomas represent less than 3%, while schwannomas of the obturator nerve are extremely rare. We report the case of a male patient with significant functional compromise of the left lower limb and pelvic pain who was diagnosed with a retroperitoneal tumor. The patient underwent laparoscopic surgery during which the compromise of the obturator nerve was evident. The lesion was completely resected with partial preservation of the nerve. The patient progressed with favorable functional recovery and pain relief. The histopathological examination reported a benign ancient schwannoma. We believe that this case report can help to understand a very rare condition and consider some key points such as the technique of approach and the need for preservation of the nerve structures.

Efecto analgésico del bloqueo PENG (grupo de nervios pericapsulares) en pacientes con fractura de cadera / Analgesic effect of the PENG BLOCK (pericapsular nervous group) in patients with hip fracture

Ultrasound regional blockade emerged that blocks the branches of the femoral nerve, obturator and accessory obturator that innervate the anterior hip capsule, the PENG block (group of pericapsular nerves), which by its Recent description does not have enough evidence in medical practice. To verify the analgesic effect of the PENG block in patients with hip fracture and its analgesic permanence during the first 10 hours after the block in patients admitted with a diagnosis of hip fracture, at the General Interzonal Hospital of Acute "Dr Oscar E Alende "From Mar del Plata, Argentina, in the months of May to November 2019. A prospective descriptive observational study was carried out with a total of 53 patients, hospitalized patients with a diagnosis of hip fracture, with standardized intravenous analgesic scheme and who have not yet undergone hip surgery. Pain was evaluated with the EVA scale (visual analog scale) prior to the blockage, and then at 30 min and 10 hours after the blockade, 15 ml of 1% lidocaine and 15 ml of bupivacaine at 0 were used. 25%, convex or linear ultrasound probe according to patient weight and 100 mm needle. In order to reproduce and evaluate the pain, the patients had a 30º flexion of the hip. Prior to the blockade, 66% of the patients had severe pain and 34% moderate pain, none presented mild pain or absence, both at thirty minutes and ten hours after the blockade, no patient presented severe pain and all patients presented analgesia with a decrease in more than three points on the VAS scale, in some cases reaching a decrease of 10 points on that scale. The PENG block is a regional anesthesia technique that provides very good analgesia to patients with hip fractures, therefore, it is an excellent saving strategy for systemic analgesics. Knowing the analgesia provided by the blockade at 30 min and at 10 h, it could be performed both in the preoperative period for the transfer and mobilization of the patient, as well as in the postoperative period, which could save the use of opioids and decrease hospital stay.

INTRODUCCIÓN La fractura de cadera es una emergencia ortopédica común en ancianos asociada a gran morbimortalidad, una adecuada analgesia regional perioperatoria determina un ahorro en el uso de analgésicos sistémicos. Recientemente, en el año 2018, surgió un nuevo bloqueo regional ecoguiado muy prometedor que bloquea las ramas del nervio femoral, obturador y obturador accesorio que inervan la capsula anterior de la cadera, el bloqueo PENG (grupo de nervios pericapsulares), el cual por su reciente descripción no cuenta con la suficiente evidencia en la práctica médica. OBJETIVOS: Comprobar el efecto analgésico del bloqueo PENG en pacientes con fractura de cadera y su permanencia analgésica durante las 10 primeras horas posteriores al bloqueo en los pacientes internados con diagnóstico de fractura de cadera, en el Hospital Interzonal General de Agudos "Dr. Oscar E Alende" de Mar del Plata, Argentina, en los meses de mayo a noviembre del 2019. MATERIALES Y MÉTODOS: Se realizó un estudio observacional descriptivo prospectivo con un total de 53 pacientes, se incluyeron pacientes internados con diagnóstico de fractura de cadera, con esquema analgésico endovenoso estandarizado y que aún no hayan sido sometido a cirugía de cadera. Se evaluó el dolor con la escala EVA (escala análoga visual) previo al bloqueo, y luego a los 30 min y a las 10 Hs de haber realizado el bloqueo, para este se utilizaron 15 ml lidocaína 1% y 15 ml de bupivacaína al 0,25%, sonda ecográfica convexa o lineal según el peso del paciente y aguja 100 mm. Para reproducir y evaluar el dolor se les realizo a los pacientes una flexión de 30º de la cadera. RESULTADOS: Previo al bloqueo el 66% de los pacientes tuvieron dolor severo y 34% dolor moderado, ninguno presentaba dolor leve o ausencia del mismo, tanto a los treinta minutos como a las diez horas posteriores al bloqueo ningún paciente presento dolor severo y todos los pacientes presentaron analgesia con una disminución en más de tres puntos en la escala de EVA, llegando en algunos casos a una disminución de 10 puntos de dicha escala. CONCLUSIONES: El bloqueo PENG es una técnica de anestesia regional que brinda muy buena analgesia a los pacientes con fractura de cadera, por consiguiente, es una excelente estrategia ahorradora de analgésicos sistémicos. Conociendo la analgesia que brinda el bloqueo a los 30 min y a las 10 h de realizado, se podría realizar dicho bloqueo tanto en el preoperatorio para el traslado y movilización del paciente, como en el post-operatorio, lo que podría ahorrar el uso de opioides y disminuir la estancia hospitalaria.

Obturator nerve injury and repair during laparoscopic lymphadenectomy. Case report and review of the literature / Lesión y reparación laparoscópica de nervio obturador en linfadenectomía laparoscópica. reporte de caso y revisión de la literatura

RESUMEN Objetivo: presentar el caso de una lesión del nervio obturador durante linfadenectomía laparoscópica y su reparación por la misma vía en el mismo tiempo quirúrgico, y realizar una revisión de la literatura de la presentación de este tipo de lesiones, así como de la técnica utilizada, el momento de su reparación y los resultados de la rehabilitación. Materiales y métodos: se presenta el caso de una mujer de 29 años atendida en el Instituto Nacional de Cancerología en Bogotá, Colombia, con diagnóstico clínico de carcinoma escamocelular de cérvix estadio Ib1, a quien se le practicó traquelectomía radical más linfadenectomía pélvica bilateral por el deseo de preservar la fertilidad. Durante el procedimiento se advirtió una sección completa del nervio obturador, la cual se reparó inmediatamente por vía laparoscópica. Se realizó una búsqueda de la literatura en la base de datos Medline vía PubMed. Los términos utilizados para la búsqueda fueron: "Obturator Nerve", "Lymph Node Excision", "Trauma", "Nervous System". Se buscaron series y reportes de caso, cohortes y artículos de revisión desde 1968 hasta septiembre 2018. La búsqueda se limitó a idiomas español e inglés. Resultados: se incluyeron ocho estudios, todos reportes de caso. Un total de seis de los casos presentaron sección completa del nervio advertida intraquirúrgicamente. En cuatro casos se realizó la reparación por medio de anastomosis términoterminal, tres casos con reconstrucción utilizando injerto de nervio sural y un caso con neurolisis y anastomosis término-terminal, todos por vía laparoscópica. En el seguimiento a nueve meses, tres pacientes recuperaron totalmente la función. Conclusión: los estudios encontrados fueron reportes de caso, la lesión más frecuente es la sección completa del nervio; se encuentran varias técnicas de reparación del nervio. La recuperación al año no es total en un importante número de casos reportados

ABSTRACT Objective: To report a case of obturator nerve injury during laparoscopic lymphadenectomy and repair through the same approach during the same surgical procedure; and to present a review of the literature on this type of injury, techniques used, timing of the repair, and rehabilitation outcomes. Materials and Methods: Case presentation of a 29-year-old woman seen at the National Cancer Institute (Instituto Nacional de Cancerología) in Bogotá, Colombia. The patient had a clinical diagnosis of stage Ib1 squamous cell carcinoma of the cervix and was taken to radical trachelectomy plus bilateral pelvic lymphadenectomy because of her wish to preserve fertility. During the procedure, a complete dissection of the obturator nerve was recognized and repaired immediately through the laparoscopic approach. A literature search was conducted in the Medline database via PubMed. The terms used for the search were "Obturator Nerve," "Lymph Node Excision," "Trauma," "Nervous System". The search was limited to publications in Spanish and English and included case series and reports, cohorts and review articles published between 1968 and September 2018. Results: Eight studies were included, all of them case reports. In six cases, complete sectioning of the nerve was recognized during surgery. In four cases, end-to-end anastomosis was used for repair; three cases were reconstructed using sural nerve grafting; and one case was managed with neurolysis and end-to-end anastomosis. All cases were approached laparoscopically. Over a nine-month follow-up period, three patients recovered full nerve function. Conclusion: The studies retrieved were all case reports, the most frequent injury being complete nerve sectioning. Several nerve repair techniques were used. Recovery after one year was not complete in a significant number of the cases reported.

Treatment of chronic osteoarthritic hip pain with phenol neurolysis of the obturator nerve Quadfen1 / Tratamento da dor crônica na osteoartrite do quadril com neurólise do nervo obturador com fenol Quadfen1

The conservative treatment of osteoarthritis (OA) of the hip is essentially symptomatic, seeking to relieve pain and optimize function. Despite presenting great clinical effect, hip arthroplasty may have restrictions, and in these situations, the neurolytic blockade of the anterior branch of the obturator nerve can be a therapeutic alternative, since it stops the afferent pain from the hip joint. Objective: To describe the results of treating patients with severe OA of the hip by applying phenol to the obturator nerve. Method: Twelve consecutive patients with OA of the hip, refractory to conservative treatment, were recruited to have the obturator nerve localized through electrostimulation and blocked with phenol. They were evaluated in terms of pain intensity via the visual analogue scale (VAS), pressure dolorimetry in the medial and lateral gluteus medius, gluteus minimus, and piriformis, and quality of life by the Harris Hip Score (HHS) at baseline (BL) after 1 (M1), 2 (M2), and 6 months (M6). Results: The patients were between 30 and 72 years old with an avarege of 47.5 ± 1.7 years old, 5 of them were women. Three patients were excluded for not being able to come for follow up evaluations. VAS values vaieded from 8.2 ±.0.9 at BL to 6.6 ± 1.7 at M1, 6.5 ± 1.7 at M2, and 7.3 ± 1 in M6 (p=0.0094). As to the HHS, the values were BL:33.27 ± 2.9; M1:39.2 ± 6.4; M2:40.2 ± 8.1, and M6: 38.8 ± 9.7 in the final evaluation (p=0,040). For dolorimetry, non significant variation was BL: 11±5.7, M1: 7.9±2.2; M2: 10.9±5.6; M6: 8.1 ± 1.6 (p 0.69). Conclusion: The application of phenol to the anterior branch of the obturator nerve can be an alternative in the treatment of severe OA of the hip in patients with restrictions to Total Hip Replacement (THR), since it reduces pain and improves quality of life.

O tratamento conservador da osteoartrite (OA) do quadril é essencialmente sintomático, visando alívio da dor e otimização da funcionalidade. Apesar de apresentar grande efeito clínico, a artroplastia quadril pode ter restrições, nestas situações o bloqueio do ramo anterior do nervo obturador (RAO) pode ser uma alternativa terapêutica, uma vez que interrompe a aferência dolorosa da articulação do quadril. Objetivo: Descrever os resultados do tratamento de pacientes com OA grave do quadril por meio da aplicação de fenol no nervo obturatório. Método: Nove pacientes com OA de quadril resistente ao tratamento conservador que se apresentaram consecutivamente ao nosso serviço foram submetidos à aplicação de fenol no nervo obturatório com localização por meio de eletroestimulação e avaliados quanto a intensidade de dor pela escala visual analógica (EVA), dolorimetria de pressão e qualidade de vida pelo Haris Hip Score (HHS) após 01, 02 e 06 meses. Resultados: Foram selecionados 12 pacientes que preenchiam os critérios de inclusão e exclusão, destes, 3 foram excluídos após não conseguirem mais comparecer para as avaliações. Os valores médios de EVA variaram de 8,2 ±.0,9 na medida basal para 6,6 ± 1,7 ao final de um mês, 6,5 ± 1,7 ao final de dois meses e 7,3 ± 1 com 06 meses (p=0,0094). Quanto ao HHS, os valores foram 33,27 ± 2,9; 39,2 ± 6,4; 40,2 ± 8,1 e 38,8 ± 9,7, na avaliação final. A última variável analisada foi a Dolorimetria, onde foi realizada a média entre os valores atingidos pela avaliação com o dolorímetro no glúteo médio medial, glúteo médio lateral, glúteo mínimo e piriforme. Na avaliação inicial média de 11±5,7, 7,9±2,2 no final do primeiro mês, 10,9±5,6 no segundo e no 6º mês 8,1±1,6. Ao aplicarmos o teste ANOVA, não foi observado diferença estatística (p 0,69). Conclusão: A aplicação de Fenol em RAO pode ser uma alternativa no tratamento da OA de quadril grave em pacientes com restrições à realização de ATQ, pois implica em redução da dor e melhora da qualidade de vida.

Three Cases of Gait Improvement after Rehabilitation Management in Corticobasal Syndrome

Corticobasal syndrome (CBS) is characterized by asymmetric dystonia, and myoclonus accompanied by higher cortical features including apraxia, alien limb phenomena, cortical sensory loss. Here, we report treatment course of 3 CBS patients. Asymmetric dystonia was seen in the first and second cases, a cortical sensory loss was seen in the third case and left lower limb apraxia was common in all cases. In the first and second cases, we performed an alcohol block on the obturator nerve and injected botulinum toxin into the lower leg to reduce dystonia. In the third case, patient was treated with a robotic assisted gait training, whole body therapeutic pool and gait training with laser pointer visual cueing. After appropriate treatment for patients, all 3 cases showed improvement in gait.

A Morphometric Study of the Obturator Nerve around the Obturator Foramen

OBJECTIVE: Obturator neuropathy is a rare condition. Many neurosurgeons are unfamiliar with the obturator nerve anatomy. The purpose of this study was to define obturator nerve landmarks around the obturator foramen. METHODS: Fourteen cadavers were studied bilaterally to measure the distances from the nerve root to relevant anatomical landmarks near the obturator nerve, including the anterior superior iliac spine (ASIS), the pubic tubercle, the inguinal ligament, the femoral artery, and the adductor longus. RESULTS: The obturator nerve exits the obturator foramen and travels infero-medially between the adductors longus and brevis. The median distances from the obturator nerve exit zone (ONEZ) to the ASIS and pubic tubercle were 114 mm and 30 mm, respectively. The median horizontal and vertical distances between the pubic tubercle and the ONEZ were 17 mm and 27 mm, respectively. The shortest median distance from the ONEZ to the inguinal ligament was 19 mm. The median inguinal ligament lengths from the ASIS and the median pubic tubercle to the shortest point were 103 mm and 24 mm, respectively. The median obturator nerve lengths between the ONEZ and the adductor longus and femoral artery were 41 mm and 28 mm, respectively. CONCLUSION: The obturator nerve exits the foramen 17 mm and 27 mm on the horizontal and sagittal planes, respectively, from the pubic tubercle below the pectineus muscle. The shallowest area is approximately one-fifth medially from the inguinal ligament. This study will help improve the accuracy of obturator nerve surgeries to better establish therapeutic plans and decrease complications.

Origens e distribuições do nervo obturatório em fetos de javalis (Sus scrofa scrofa Linnaeu ­ 1758) / Origins and distribution of the obturatorius nerve in wild boars fetuses (Sus scrofa scrofa Linnaeu ­ 1758)

A criação de javalis vem crescendo no Brasil devido à procura de um produto de qualidade e com propriedades nutricionais. Analisou-se a origem e distribuição dos nervos obturatórios em 19 fetos de javalis (Sus scrofa scrofa) visando fornecer dados morfológicos para anatomia comparativa e áreas afins. A fixação destes animais em solução aquosa de formaldeído a 10% ocorreu mediante diferentes pontos de injeções subcutâneas, intramusculares e intracavitárias, bem como por imersão dos referidos exemplares em recipientes com a mesma solução por um período mínimo de 48 horas. Foi observado que o referido nervo originou-se dos ramos ventrais de L4 a L6. Distribui-se para os músculos obturatório externo, grácil, adutor e pectíneo. Pode-se afirmar que tanto a origem como a distribuição do nervo obturatório em javalis se assemelha aos padrões evidenciados em suínos domésticos.

The creation of wild boars is increasing in Brazil due to demand for a quality product and excellent nutritional properties. This study analyzed the origin and distribution of the obturatorius nerve in 19 fetuses of wild boar (Sus scrofa scrofa) in order to provide morphological data for comparative anatomy and areas related. The introduction of these animals in aqueous formaldehyde 10% was by different points of subcutaneous, intramuscular and intracavitary injections, as well as by immersion of those specimens, in containers of the same solution for a minimum of 48 hours. It was noted that the nerve was originated from the ventral branches of L4, L5 and L6. Concerning to distribution, the nerve dispatched ventral branches to the external obturator, gracilis, adductor and pectineus muscles. It can be stated that both the origin and distribution of the obturatorius nerve in wild boars is similar to the patterns evidenced in domestic swine.

Usefulness of Ultrasound-Guided Lower Extremity Nerve Blockade in Surgery for Patellar Fracture

PURPOSE: To evaluate the usefulness of ultrasound-guided nerve blockade in patellar fracture surgery. MATERIALS AND METHODS: Twenty-three patients who underwent metal fixation under ultrasound-guided lower extremity blockade after diagnosis of patellar fracture from July 2011 to June 2012 were enrolled in this study. Under ultrasound guidance, femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and sciatic nerve blockades were performed. For evaluation of anesthesia, interference with overall surgery, such as intraoperative knee pain and tourniquet pain, was checked. Individual anesthetic complications, satisfaction with nerve blocks, and choice of future anesthesia method were investigated. RESULTS: Nineteen patients underwent surgery without any pain and 4 patients with mild pain. Satisfaction was excellent in 17 patients, good in 5, and unsatisfactory in 1. No complications such as infection or nerve injury occurred. In terms of selection of future anesthesia, 22 patients chose a nerve blockade of the lower extremity under ultrasound guidance, and one chose general anesthesia. CONCLUSIONS: Overall, ultrasound-guided nerve block of the lower extremity for patellar fracture surgery showed satisfactory results. Therefore, it could be a useful method to prevent complications associated with general or spinal anesthesia.

Neurologic Injury within Pelvic Ring Injuries

PURPOSE: To evaluate the incidence of neurologic injury in pelvic ring injuries and to assess the risk factors for neurologic injury related to pelvic fractures. MATERIALS AND METHODS: Sixty-two patients with the pelvic ring injury were enrolled in the study from March 2010 to May 2013. When the neurologic injury was suspected clinically, the electro-diagnostic tests were performed. Combined injuries, fracture types, and longitudinal displacements were examined for correlations with the neurologic injury. RESULTS: There were 7 cases of AO/OTA type A, 37 cases of type B, and 18 cases of type C. Among them, 25 patients (40%) had combined spine fractures, and the average of longitudinal displacement was 7 mm (1-50 mm). Of the 62 patients, 13 (21%) had neurologic injury related with pelvic fractures; 5 with lumbosacral plexus injury, 5 with L5 or S1 nerve injury, 2 with obturator nerve injury, and 1 case of lateral femoral cutaneous nerve injury. There were no relationships between the neurologic injuries and fracture types (p=0.192), but the longitudinal displacements of posterior ring and combined spine fractures were related to the neurologic injury within pelvic ring injury (p=0.006, p=0.048). CONCLUSION: The incidence of neurologic injury in pelvis fracture was 21%. In this study, the longitudinal displacements of posterior ring and combined spine fractures were risk factors for neurological injury in pelvic ring injury.

Neurovascular Injury in Hip Arthroplasty / 대한고관절학회지

Neurological and vascular complications following hip arthroplasty are uncommon, and their impact ranges from transient and trivial to permanent and devastating. The proximity of neural and vascular structures makes any operation on the hip potentially hazardous. Direct or indirect injuries of these structures may occur during operative exposure and subsequent procedures. Thus, complete awareness of the anatomy of the pelvis and proximal femur is required. Peripheral nerve injuries can involve either distant sites or nerves in the immediate vicinity of the hip joint. Sciatic nerve injury is the most common nerve injury following total hip arthroplasty. Femoral nerve injury is much less common and is associated with an anterior approach. Its diagnosis is often delayed, but the prognosis is generally better than with sciatic nerve injury. The superior gluteal nerve is at risk during the direct lateral approach. Obturator nerve injury is the least common type of injury and has the least functional consequences. Vascular injuries are less common but more immediately life threatening. The mechanisms of vascular injury include occlusion associated with preexisting peripheral vascular disease and vascular injury during removal of cement during screw fixation of acetabular components, cages, or structural grafts. It is critical to avoid the anterior quadrants for acetabular screw fixation. All acetabular and femoral defects should be bone-grafted to avoid inadvertent cement migration. Following these guidelines, surgeons should be able to offer the most appropriate treatment and counseling to the patients.

The Effect of Obturator Nerve Block on Hip Lateralization in Low Functioning Children with Spastic Cerebral Palsy

PURPOSE: Hip adductor spasticity has a great impact on developing hip displacement in children with cerebral palsy (CP). Obturator nerve (ON) block is less invasive intervention rather than soft tissue surgery for reduction of hip adductor spasticity. The aim of this study is to investigate the effect of ON block on hip lateralization in low functioning children with spastic CP. MATERIALS AND METHODS: The study was performed by retrospective investigation of the clinical and radiographic follow-up data of low functioning children [gross motor function classification system (GMFCS) level III to V] with spastic cerebral palsy whose hip was subluxated. Migration percentage (MP) was measured on hip radiographs and its annual change was calculated. In intervention group, ON block was done with 50% ethyl alcohol under the guidance of electrical stimulation. RESULTS: The data of 49 legs of 25 children for intervention group and the data of 41 legs of 23 children for nonintervention group were collected. In intervention group, the MP were significantly reduced at 1st follow-up and the MPs at 2nd and last follow-up did not show significant differences from initial MP. Whereas in nonintervention group, the MPs at 1st, 2nd and last follow-up were all significantly increased compared to initial MPs. CONCLUSION: ON block with ethyl alcohol is useful as an early effective procedure against progressive hip displacement in these children with spastic CP.

Acetabular Paralabral Cyst as a Rare Cause of Obturator Neuropathy: A Case Report

An acetabular paralabral cyst is a benign soft tissue cyst usually seen in association with a tear of the acetabular labrum. Acetabular paralabral cysts are often the cause of joint pain, but they rarely cause compression of the adjacent neurovascular structures. We present a case of a 63-year-old male patient who had paresis and atrophy of right hip adductor muscles. Right obturator neuropathy was confirmed through an electrodiagnostic study. In addition, magnetic resonance imaging showed a paralabral cyst in the right acetabulum which extended to the pelvic wall. The patient underwent conservative treatment without surgical procedure. The pain was decreased after 1 month of conservative therapy. The pain was decreased at the 1-month follow-up. Follow-up electromyography showed polyphasic motor unit potentials in adductor magnus and adductor longus muscles. Based on the experience of this case, an acetabular paralabral cyst should be considered as one of the rare causes of obturator neuropathy.

Peripheral nerve blockade as an exclusive approach to obturator nerve block in anterior cruciate ligament reconstructive surgery / 대한마취과학회지

BACKGROUND: Obturator nerve block plays an additive role on the quality of analgesia for knee surgery. Since the use of dual guidance increases the success rate of nerve blocks, we investigated the feasibility of performing anterior cruciate ligament reconstruction under dual-guided blockade of obturator with femoral and sciatic nerves. Furthermore, we propose a novel method for the assessment of obturator nerve block. METHODS: Fifty-seven patients undergoing anterior cruciate ligament repair were studied. Neurostimulating needles were guided out-of-plane by ultrasound. To induce the obturator nerve block, 10 ml of ropivacaine 0.5% were injected after eliciting contractions of adductor longus, brevis and magnus followed by block assessment for 30 minutes by examining the patient lift and left down the leg. RESULTS: The sonographic recognition of obturator nerve was easy and quick in all cases. Time for applying the block was 119.9 +/- 79.2 sec. Assessing this block with lifting-leaving down the leg gave satisfactory results in 24.0 +/- 5.07 min. After performing femoral-sciatic blocks, the inflation of tourniquet resulted in VAS score of > 0 in 2/57 patients and operation in 12/57. Total dose of fentanyl was 120.1 +/- 64.6 microg and of midazolam 1.86 +/- 0.8 mg. In 6 patients propofol was administered for sedation and 1 of them required ventilation with laryngeal mask airway, converting the anesthesia technique to general anesthesia. CONCLUSIONS: Our data suggest that anterior cruciate ligament reconstruction can be performed under obturator-femoral-sciatic blocks. Identification of obturator nerve with ultrasound is easy and the block can be assessed by observing how the patient lifts and leaves down the leg.

Obturator Nerve Block Using Ultrasound-guided Intraneural Alcohol Injection in Patient with Hip Adductor Spasticity

OBJECTIVE: To investigate the effects of obturator nerve blocks with ultrasound guided intraneural alcohol injection. METHOD: Nine quadriplegic patients suffering hip adductor spasticity were included in this study. The obturator nerve was identified at just below inguinal ligament area on anteromedial surface of upper leg at supine position. An 23 G needle was inserted into anterior branch of obturator nerve under real time ultrasonography. The 50% alcohol solution was injected 3~5 ml at a time within the epineurium of the anterior branch of obturator nerve until the expanding nerve was visualized. We examed modified Ashworth scale (MAS) of hip adductor and passive range of movement of hip abduction at supine position at study entry, 1, 4, and 12 weeks after ultrasound guided intraneural injection. RESULTS: There were statistically significant improvement was seen in MAS of hip adductors and hip abduction angle at 1, 4, and 12 weeks after ultrasound guided intraneural injection, compared with parameters measured at previous injection (p<0.05). CONCLUSION: Ultrasound guided intraneural alcohol injection into anterior branch of obturator nerve for treatment of hip adductor spasticity in patients with quadriplegia is an effective and safe procedure for relieving localized spasticity of the hip adductors.

Neuropatía del nervio obturador secundaria a quiste sinovial: reporte de caso / Obturator nerve entrapment caused by a synovial cyst: case report

El nervio obturador (L2-L4) inerva músculos cuya función principal es la aducción del muslo y, en menor grado, su rotación externa, y recoge la sensibilidad de la cara interna del muslo. Su lesión aislada es infrecuente y suele ser compresiva o traumática. Se presenta el caso de un hombre de 37 años con clínica de neuropatía del nervio obturador secundaria a un quiste sinovial de la articulación de la cadera, que por lo infrecuente del caso sufrió un retraso tanto en el diagnóstico como en el tratamiento definitivo.

Spinal Nerve Compositions of the Terminal Branches of the Lumbosacral Plexus / 체질인류학회지

The purpose of this study was to classify the spinal nerve compositions of the terminal branches of the lumbosacral plexus, providing data of their participating quantities. Twenty-five sides of the lumbosacral plexus extracted from Korean adult cadavers were used in this study. The iliohypogastric nerve was mostly arisen from L1 (88.2%, thickness L1 0.7 mm). The ilioinguinal nerve was arisen from only L1 (100%, thickness L1 0.6 mm). The genitofemoral nerve was commonly arisen from L1 and L2 (62.5%, thickness L1 0.6 mm, L2 0.7 mm). The lateral femoral cutaneous nerve was classified into 4 types, and the most common type was that L2 and L3 composed this nerve (56.0%, thickness L2 0.8 mm, L3 0.4 mm). The femoral nerve was classified into 2 types, and it was usually composed of L2, L3 and L4 (88.0%, thickness L2 1.4 mm, L3 2.7 mm, L4 2.3 mm). The obturator nerve was arisen from L2, L3 and L4 in all cases (100%, thickness L2 0.5 mm, L3 1.3 mm, L4 1.1 mm). The common fibular component of sciatic nerve was mostly arisen from L4, L5, S1 and S2 (84.0%, thickness L4 0.9 mm, L5 2.0 mm, S1 2.1 mm, S2 1.2 mm). The tibial component of sciatic nerve was mainly arisen from L4, L5, S1 and S2 (96.0%, thickness L4 0.9 mm, L5 1.9 mm, S1 2.2 mm, S2 1.9 mm). The superior gluteal nerve was commonly derived from L4, L5 and S1 (56.0%, thickness L4 0.7 mm, L5 1.1 mm, S1 0.9 mm). The inferior gluteal nerve was comprised of L5, S1 and S2 in several cases (54.2%, thickness L5 0.9 mm, S1 1.3 mm, S2 0.8 mm). The posterior femoral cutaneous nerve was composed of S1 and S2 in higher freqeuncy (40.0%, thickness S1 0.9 mm, S2 1.0 mm, S3 0.8 mm). The perforating cutaneous nerve was arisen from S2 and S3 in higher frequency (56.0%, thickness S1 0.7 mm, S2 0.9 mm, S3 1.1 mm). The pudendal nerve was derived from S3 in many cases (52.9%, thickness S3 1.5 mm). These anatomical results may be helpful to predict the spinal nerve root lesions of the lumbosacral plexus.