Skin and not dorsal root stimulation reduces hypertonus in thoracic motor complete spinal cord injury: a single case report.

On demand and localized treatment for excessive muscle tone after spinal cord injury (SCI) is currently not available. Here, we examine the reduction in leg hypertonus in a person with mid-thoracic, motor complete SCI using a commercial transcutaneous electrical stimulator (TES) applied at 50 or 150 Hz to the lower back and the possible mechanisms producing this bilateral reduction in leg tone. Hypertonus of knee extensors without and during TES, with both cathode (T11-L2) and anode (L3-L5) placed over the spinal column (midline, MID) or 10 cm to the left of midline (lateral, LAT) to only active underlying skin and muscle afferents, was simultaneously measured in both legs with the pendulum test. Spinal reflexes mediated by proprioceptive (H-reflex) and cutaneomuscular reflex (CMR) afferents were examined in the right leg opposite to the applied LAT TES. Hypertonus disappeared in both legs but only during thoracolumbar TES, and even during LAT TES. The marked reduction in tone was reflected in the greater distance both lower legs first dropped to after being released from a fully extended position, increasing by 172.8% and 94.2% during MID and LAT TES, respectively, compared with without TES. Both MID and LAT (left) TES increased H-reflexes but decreased the first burst, and lengthened the onset of subsequent bursts, in the cutaneomuscular reflex of the right leg. Thoracolumbar TES is a promising method to decrease leg hypertonus in chronic, motor complete SCI without activating spinal cord structures and may work by facilitating proprioceptive inputs that activate excitatory interneurons with bilateral projections that in turn recruit recurrent inhibitory neurons.NEW & NOTEWORTHY We present proof of concept that surface stimulation of the lower back can reduce severe leg hypertonus in a participant with motor complete, thoracic spinal cord injury (SCI) but only during the applied stimulation. We propose that activation of skin and muscle afferents from thoracolumbar transcutaneous electrical stimulation (TES) may recruit excitatory spinal interneurons with bilateral projections that in turn recruit recurrent inhibitory networks to provide on demand suppression of ongoing involuntary motoneuron activity.

Sacral Anterior Root Stimulation and Visceral Function Outcomes in Spinal Cord Injury-A Systematic Review of the Literature Over Four Decades.

OBJECTIVE: Sacral anterior root stimulation (SARS) was developed 40 years ago to restore urinary and bowel functions to individuals with spinal cord injury. Mostly used to restore lower urinary tract function, SARS implantation is coupled with sacral deafferentation to counteract the problems of chronic detrusor sphincter dyssynergia and detrusor overactivity. In this article, we systematically review 40 years of SARS implantation and assess the medical added value of this approach in accordance with the PRISMA guidelines. We identified 4 axes of investigation: 1) impact on visceral functions, 2) implantation safety and device reliability, 3) individuals' quality of life, and 4) additional information about the procedure. METHODS: A systematic review was performed. Three databases were consulted: PubMed, EBSCOhost, and Pascal. A total of 219 abstracts were screened and 38 articles were retained for analysis (1147 implantations). RESULTS: The SARS technique showed good clinical results (85.9% of individuals used their implant for micturition and 67.9% to ease bowel movements) and improved individual quality of life. Conversely, several sources of complications were reported after implantation (e.g., surgical complications and failure). CONCLUSIONS: Despite promising results, a decline in implantations was observed. This decline can be linked to the complication rate, as well as to the development of new therapeutics (e.g., botulinum toxin) and directions for research (spinal cord stimulation) that may have an impact on people. Nevertheless, the lack of alternatives in the short-term suggests that the SARS implant is still relevant for the restoration of visceral functions after spinal cord injury.

The eight cervical nerve and its role in tinnitus.

INTRODUCTION: The eight cervical nerve might be a source of input to the auditory system. OBJECTIVES: The object was to assess the efficacy of infiltration of the eight cervical nerve root for treating tinnitus patients and to find indicators for a successful result. DESIGN: Retrospective cohort study. Subjects were 79 tinnitus patients visiting our clinic in a three-year period and who were treated with infiltration of the eight cervical nerve root. RESULTS: Twenty-six percent of the tinnitus patients had a reduction of their tinnitus following an infiltration of the eight cervical nerve root. Most of the successfully treated patients rated the effect of therapy as a moderate reduction of 25% to 50%. Fifty percent of the successful treated patients still had benefit at 6.6 months. In 5% of the patients, their tinnitus was aggravated after the infiltration of the eight cervical nerve roots. Patients with a hearing loss at 500 Hz that exceed the hearing loss at 2 kHZ responded the most to infiltration of the eight cervical nerve. CONCLUSION: Infiltration of the eight cervical nerve root reduced the intensity of tinnitus in 26% of the cohort of 79 tinnitus patients with a moderate to good effect. This therapy for tinnitus patients' needs to be considered, especially in those with a hearing loss at 500 Hz that exceed the hearing loss at 2 kHZ.

Upper Cervical Nerves Can Induce Tinnitus.

INTRODUCTION: Treating cervical spine disorders can result in a reduction of tinnitus. OBJECTIVES: The object of the study was to ascertain the benefit of therapy of the third and fourth cervical nerves in reducing tinnitus and to assess parameters indicating a long-term relief. DESIGN: Subjects were 37 tinnitus patients who were treated with infiltration of the third and fourth cervical nerves. Clinical data form these patients were reviewed retrospectively. An independent perceiver evaluated the long-term effect of the therapy by telephone interview. RESULTS: In a group of tinnitus patients, 19% of the patients reported less tinnitus after therapy of the third and fourth cervical nerves. Most of the patients had a moderate reduction of 25% to 50%. At 3.8 months, 50% of the successful treated patients still had a positive effect. No adverse events of the procedure were observed. The combination of an evident anterior spur at the third cervical vertebrae together with less hearing at 2 kHz indicate patients who responded the best to therapy of the third and fourth cervical nerves. CONCLUSIONS: Treating cervical spine disorders can reduce tinnitus. In a group of tinnitus patients, 19% of the patients had less tinnitus after therapy of the C3 and C4. Screening of tinnitus patients is needed for the proper selection of the ones who could benefit from a somatic approach. In our study, the combination of an evident anterior spur at the third cervical vertebrae together with less hearing at 2 kHz indicate patients who responded the best following therapy of the C3 and C4.

Neurostimulation in neurogenic patients.

PURPOSE OF REVIEW: To provide an overview of available electrical stimulation devices in neurogenic patients with lower urinary tract disease. RECENT FINDINGS: It is advocated to do more studies in neurogenic patients as results seem promising and useful but most studies did not include neurogenic patients or neurogenic patients were not analyzed or reported separately. Most studies included a small heterogenous neurogenic group with multiple pathophysiologic origin focusing on effect of a treatment instead of results of a treatment in a specific neurogenic group. Neuromodulation or stimulation has the advantage that it acts on different organs, like bladder and bowel, so can treat neurogenic patients, who mostly suffer from multiple organ failure. SUMMARY: Brindley procedure, sacral neuromodulation (SNM) and posterior tibial nerve stimulation (PTNS) are available for a while already. The Brindley procedure (including sacral anterior root stimulation in combination with a rhizotomy of posterior sacral roots) is developed for selected spinal cord injury patient with a complete spinal injury, and has shown results for many years in neurogenic patients. An alternative to the rhizotomy is not established yet. SNM and PTNS are other modalities that are used in nonneurogenic patients, but are not yet indicated and much studied in neurogenic patients.

Effect of spinal anterior root stimulation and sacral deafferentation on bladder and sexual dysfunction in spinal cord injury.

BACKGROUND: Spinal cord injury (SCI) is a highly devastating injury with a variety of complications; among them are neurogenic bladder, bowel, and sexual dysfunction. We aimed to evaluate the effect of sacral anterior root stimulation with sacral deafferentation (SARS-SDAF) on neurogenic bladder and sexual dysfunction in a large well-defined spinal cord injury cohort. METHODS: In the manner of cross-sectional study, subjects undergone SARS-SDAF between September 1986 and July 2011 answered a questionnaire concerning conditions before and after surgery in the department of Neuro-Urology, Bad Wildungen, Germany. RESULTS: In total 287 of 587 subjects were analyzed. Median age was 49 years (range 19-80), median time from SCI to surgery was 10 years (range 0-49), and from surgery to follow-up 13 years (range 1-25). Of the analyzed subjects, 100% of both gender used SARS for bladder emptying. On the visual analogue scale (VAS) ranging from 0 to 10 (best), satisfaction with SARS-SDAF was 10 concerning bladder emptying, however 5 and 8 regarding sexual performance, for female and male users, respectively. Baseline and follow-up comparison showed a decline in self-intermittent catheterization (p < 0.0001), partial catheterization by attendant (p = 0.0125), complete catheterization and suprapubic catheterization (p < 0.0001), transurethral catheterization (p < 0.0011), and fewer cases of involuntary urine leakage (p < 0.0001). CONCLUSIONS: The SARS-SDAF is a beneficial multi-potential treatment method with simultaneous positive effect on multi-organ dysfunction among SCI subjects.

Boosted Regeneration and Reduced Denervated Muscle Atrophy by NeuroHeal in a Pre-clinical Model of Lumbar Root Avulsion with Delayed Reimplantation.

The "gold standard" treatment of patients with spinal root injuries consists of delayed surgical reconnection of nerves. The sooner, the better, but problems such as injury-induced motor neuronal death and muscle atrophy due to long-term denervation mean that normal movement is not restored. Herein we describe a preclinical model of root avulsion with delayed reimplantation of lumbar roots that was used to establish a new adjuvant pharmacological treatment. Chronic treatment (up to 6 months) with NeuroHeal, a new combination drug therapy identified using a systems biology approach, exerted long-lasting neuroprotection, reduced gliosis and matrix proteoglycan content, accelerated nerve regeneration by activating the AKT pathway, promoted the formation of functional neuromuscular junctions, and reduced denervation-induced muscular atrophy. Thus, NeuroHeal is a promising treatment for spinal nerve root injuries and axonal regeneration after trauma.

[Bipolar stimulation may improve the efficacy of the percutaneous nerve evaluation test of sacral neuromodulation]. / Die bipolare Stimulation kann die Erfolgsrate des Peripheren Nervenevaluationstests der sakralen Neuromodulation verbessern.

Purpose This study evaluates the hypothesis that bipolar stimulation of the S3 and S4 sacral roots may enhance the efficacy of the percutaneous nerve evaluation (PNE) test. Material and Methods In this case-control-study, we enrolled 43 patients undergoing bipolar PNE and 57 controls undergoing unipolar PNE. For bipolar PNE, four test electrodes were placed at the bilateral S3 and S4 roots. The electrodes at the S3 and S4 roots of each side were connected to obtain bipolar stimulation. The test protocol over eight days included unilateral and bilateral stimulation of the S3 and S4 sacral roots. Eight days after implantation, the electrodes were removed and test results from bladder diaries were collected. Results The unipolar test procedure was successful in 47 % (27/57) of cases. The bipolar test procedure was successful in 58 % (25/43). In the bipolar group, 63 % (12/19) of patients with neurogenic tract dysfunction profited from treatment, vs. 57 % (13/23) in the unipolar group. Patients without a neurologic disease had a successful test in 58 % (14/24) of cases treated with bipolar PNE vs. 41 % (14/24) treated with unipolar PNE. Multivariate analysis did not reveal a statistically significant difference between groups. Conclusion Although not significant in this population, bipolar PNE may improve efficacy compared to the unipolar test procedure. Similar observations were made in subgroups of neurogenic and non-neurogenic bladder dysfunctions.

Electroacupuncture improves gait locomotion, H-reflex and ventral root potentials of spinal compression injured rats.

This study explored the effect of electroacupuncture stimulation (EA) on alterations in the Hoffman reflex (H-reflex) response and gait locomotion provoked by spinal cord injury (SCI) in the rat. A compression lesion of the spinal cord was evoked by insufflating a Fogarty balloon located in the epidural space at the T8-9 spinal level of adult Wistar male rats (200-250 gr; n=60). In different groups of SCI rats, EA (frequencies: 2, 50 and 100Hz) was applied simultaneously to Huantiao (GB30), Yinmen (BL37), Jizhong (GV6) and Zhiyang (GV9) acupoints from the third post-injury day until the experimental session. At 1, 2, 3 and 4 post-injury weeks, the BBB scores of the SCI group of rats treated with EA at 50Hz showed a gradual but greater enhancement of locomotor activity than the other groups of rats. Unrestrained gait kinematic analysis of SCI rats treated with EA-50Hz stimulation showed a significant improvement in stride duration, length and speed (p<0.05), whereas a discrete recovery of gait locomotion was observed in the other groups of animals. After four post-injury weeks, the H-reflex amplitude and H-reflex/M wave amplitude ratio obtained in SCI rats had a noticeable enhancement (217%) compared to sham rats (n=10). Meanwhile, SCI rats treated with EA at 50Hz manifested a decreased facilitation of the H-reflex amplitude and H/M amplitude ratio (154%) and a reduced frequency-dependent amplitude depression of the H-reflex (66%). In addition, 50 Hz-EA treatment induced a recovery of the presynaptic depression of the Gs-VRP evoked by PBSt conditioning stimulation in the SCI rat (63.2±8.1%; n=9). In concordance with the latter, it could be suggested that 50 Hz-EA stimulation reduced the hyper-excitability of motoneurons and provokes a partial improvement of the locomotive performance and H reflex responses by a possible recovery of presynaptic mechanisms in the spinal cord of experimentally injured rats.

Evaluation of a granulated formula for the nerve root type and vertebral artery type of cervical spondylosis: a multicenter, single-blind, randomized, controlled, phase â ¢ clinical trial.

OBJECTIVE: To evaluate the effectiveness and safety of cervical spondylosis formula granules in reducing the symptoms of patients with the nerve root type and the vertebral artery type of cervical spondylosis. METHODS: This was a multicenter, single-blind, randomized, controlled trial. From April 2002 to November 2003, 499 patients were randomly assigned to either the treatment or the control group. The treatment group was orally administered granules prepared with a formula for cervical spondylosis, while the control group was given Jingfukang granules. The treatment course was 1 month for both groups. RESULTS: In patients with the nerve root type of cervical spondylosis, the total effect rate in the treatment group (87.21% ) was significantly higher than that in the control group (80.70%, P < 0.01). After the treatment period in both groups, the treatment group had a significantly greater rate of resolution of pain, numbness of the upper limbs, muscle strength of the upper limbs, and fatigue than the control group (all P < 0.05). In patients with the vertebral artery type of cervical spondylosis, the total effect rate in the treatment group (82.07%) was similar to that in the control group (71.21% , P > 0.05). After the treatment period in both groups, the treatment group had a significantly greater rate of resolution of weakness of the waist and knees than the control group (P < 0.05). CONCLUSION: The cervical spondylosis formula granules significantly improve numbness, muscle strength, and fatigue, and reduce pain in patients with the nerve root type of cervical spondylosis, and improve the weakness of the waist and knees in patients with the vertebral artery type of cervical spondylosis.

Sacral neuromodulation of nociceptive bladder overactivity in cats.

AIMS: To investigate the effects of electrical stimulation of sacral dorsal/ventral roots on irritation-induced bladder overactivity, reveal possible different mechanisms under nociceptive bladder conditions, and establish a large animal model of sacral neuromodulation. METHODS: Intravesical infusion of 0.5% acetic acid (AA) was used to irritate the bladder and induce bladder overactivity in cats under α-chloralose anesthesia. Electrical stimulation (5, 15, or 30 Hz) was applied to individual S1-S3 dorsal or ventral roots at or below motor threshold intensity. Repeated cystometrograms (CMGs) were performed with/without the stimulation to determine the inhibition of bladder overactivity. RESULTS: AA irritation induced bladder overactivity and significantly (P < 0.05) reduced the bladder capacity to 62.6 ± 11.7% of control capacity measured during saline CMGs. At threshold intensity for inducing reflex twitching of the anal sphincter or toe, S1/S2 dorsal root stimulation at 5 Hz but not at 15 or 30 Hz inhibited bladder overactivity and significantly (P < 0.05) increased bladder capacity to 187.3 ± 41.6% and 155.5 ± 9.7% respectively, of AA control capacity. Stimulation of S3 dorsal root or S1-S3 ventral roots was not effective. Repeated stimulation of S1-S3 dorsal root did not induced a post-stimulation inhibition. CONCLUSIONS: This study established a cat model of sacral neuromodualation of nociceptive bladder overactivity. The results revealed that the mechanisms underlying sacral neuromodulation are different for nociceptive and non-nociceptive bladder activity.

Clinically relevant concentration of pregabalin has no acute inhibitory effect on excitation of dorsal horn neurons under normal or neuropathic pain conditions: An intracellular calcium-imaging study in spinal cord slices from adult rats.

Pregabalin is thought to exert its therapeutic effect in neuropathic pain via binding to α2δ-1 subunits of voltage-gated calcium (Ca(2+)) channels. However, the exact analgesic mechanism after its binding to α2δ-1 subunits remains largely unknown. Whether a clinical concentration of pregabalin (≈10µM) can cause acute inhibition of dorsal horn neurons in the spinal cord is controversial. To address this issue, we undertook intracellular Ca(2+)-imaging studies using spinal cord slices with an intact attached L5 dorsal root, and examined if pregabalin acutely inhibits the primary afferent stimulation-evoked excitation of dorsal horn neurons in normal rats and in rats with streptozotocin-induced painful diabetic neuropathy. Under normal conditions, stimulation of a dorsal root evoked Ca(2+) signals predominantly in the superficial dorsal horn. Clinically relevant (10µM) and a very high concentration of pregabalin (100µM) did not affect the intensity or spread of dorsal root stimulation-evoked Ca(2+) signals, whereas an extremely high dose of pregabalin (300µM) slightly but significantly attenuated Ca(2+) signals in normal rats and in diabetic neuropathic (DN) rats. There was no difference between normal rats and DN rats with regard to the extent of signal attenuation at all concentrations tested. These results suggest that the activity of dorsal horn neurons in the spinal cord is not inhibited acutely by clinical doses of pregabalin under normal or DN conditions. It is very unlikely that an acute inhibitory action in the dorsal horn is the main analgesic mechanism of pregabalin in neuropathic pain states.

[Acupuncture combined with moxibustion plaster for nerve-root type cervical spondylosis].

OBJECTIVE: To compare the clinical efficacy differences between acupuncture combined with moxi-bustion plaster and electroacupuncture (EA) for nerve-root type cervical spondylosis. METHODS: A total of 60 casesof nerve-root type cervical spondylosis were randomly divided into a plaster group and an EA group, 30 cases ineach one. Patients in the plaster group were treated with regular acupuncture at Jiaji(EX-B 2) points and ashipoints, combined with moxibustion plaster at Gaohuang (BL 43); patients in the EA group were treated with EAat identical acupoints as plaster group. The treatment was given once a day, and 5 days were taken as one course;there was an interval of 2 days between courses and totally 2 courses were performed. The pain questionnaires andquantitative score of signs and symptoms were observed before and after treatment in the two groups. The clinicalefficacy of the two groups was compared. RESULTS: The total effective rate was 96. 7% (29/30) in the plastergroup, which was not significantly different from 93. 3% (28/30) in the EA group (P>0. 05). After treatment,PRI, VAS and PPI were all reduced in the two groups (all P

Lithium accelerates functional motor recovery by improving remyelination of regenerating axons following ventral root avulsion and reimplantation.

Brachial plexus injury (BPI) often involves the complete or partial avulsion of one or more of the cervical nerve roots, which leads to permanent paralysis of the innervated muscles. Reimplantation surgery has been attempted as a clinical treatment for brachial plexus root avulsion but has failed to achieve complete functional recovery. Lithium is a mood stabilizer drug that is used to treat bipolar disorder; however, its effects on spinal cord or peripheral nerve injuries have also been reported. The purpose of this study was to investigate whether lithium can improve functional motor recovery after ventral root avulsion and reimplantation in a rat model of BPI. The results showed that systemic treatment with a clinical dose of lithium promoted motor neuron outgrowth and increased the efficiency of motor unit regeneration through enhanced remyelination. An analysis of myelin-associated genes showed that the effects of lithium started during the early phase of remyelination and persisted through the late stage of the process. Efficient remyelination of the regenerated axons in the lithium-treated rats led to an earlier functional recovery. Therefore, we demonstrated that lithium might be a potential clinical treatment for BPI in combination with reimplantation surgery.

Spinal Rhythm Generation by Step-Induced Feedback and Transcutaneous Posterior Root Stimulation in Complete Spinal Cord-Injured Individuals.

BACKGROUND: The human lumbosacral spinal circuitry can generate rhythmic motor output in response to different types of inputs after motor-complete spinal cord injury. OBJECTIVE: To explore spinal rhythm generating mechanisms recruited by phasic step-related sensory feedback and tonic posterior root stimulation when provided alone or in combination. METHODS: We studied stepping in 4 individuals with chronic, clinically complete spinal cord injury using a robotic-driven gait orthosis with body weight support over a treadmill. Electromyographic data were collected from thigh and lower leg muscles during stepping with 2 hip-movement conditions and 2 step frequencies, first without and then with tonic 30-Hz transcutaneous spinal cord stimulation (tSCS) over the lumbar posterior roots. RESULTS: Robotic-driven stepping alone generated rhythmic activity in a small number of muscles, mostly in hamstrings, coinciding with the stretch applied to the muscle, and in tibialis anterior as stance-phase synchronized clonus. Adding tonic 30-Hz tSCS increased the number of rhythmically responding muscles, augmented thigh muscle activity, and suppressed clonus. tSCS could also produce rhythmic activity without or independent of step-specific peripheral feedback. Changing stepping parameters could change the amount of activity generated but not the multimuscle activation patterns. CONCLUSIONS: The data suggest that the rhythmic motor patterns generated by the imposed stepping were responses of spinal reflex circuits to the cyclic sensory feedback. Tonic 30-Hz tSCS provided for additional excitation and engaged spinal rhythm-generating networks. The synergistic effects of these rhythm-generating mechanisms suggest that tSCS in combination with treadmill training might augment rehabilitation outcomes after severe spinal cord injury.

Multi-Electrode Array for Transcutaneous Lumbar Posterior Root Stimulation.

Interest in transcutaneous electrical stimulation of the lumbosacral spinal cord is increasing in human electrophysiological and clinical studies. The stimulation effects on lower limb muscles depend on the depolarization of segmentally organized posterior root afferents and, thus, the rostro-caudal stimulation site. In previous studies, selective stimulation was achieved by varying the positions of single self-adhesive electrodes over the thoracolumbar spine. Here, we developed a multi-electrode surface array consisting of 3 × 8 electrode pads and tested its stimulation-site specificity. The array was placed longitudinally over the spine covering the T10-L2 vertebrae. Two different hydrogel layer configurations were utilized: a single layer adhered to all electrode pads of the array and a configuration comprised of eight separate strips attached to the three transverse electrode pads of each level. Voltage measurements demonstrated that an effectively focused field distribution along the longitudinal extent of the array was not accomplished when using the single continuous hydrogel layer, and segmental selective stimulation of the posterior root afferents was not possible. The separate strips produced a focused electric field distribution at the rostro-caudal level of the electrode pads selected for stimulation. This configuration allowed for the preferential elicitation of posterior root-muscle reflexes in either the L2-L4 innervated quadriceps or the L5-S2 innervated triceps surae muscle groups. Such multi-electrode array for transcutaneous spinal cord stimulation shall allow for improved control of stimulation conditions in electrophysiological studies and time-dependent and site-specific stimulation patterns for neuromodulation applications.

A double-blind randomized clinical trial on the efficacy of magnetic sacral root stimulation for the treatment of Monosymptomatic Nocturnal Enuresis.

PURPOSE: Purpose of this study was to evaluate the long term efficacy of repetitive sacral root magnetic stimulation (rSMS) in patients with monosymptomatic nocturnal enuresis (MNE). METHODS: Forty four patients were randomized to receive either sham or real repetitive sacral root magnetic stimulation (rSMS; 15 Hz with a total of 1500 pulses/session) for 10 sessions. Evaluation was performed before starting treatment, immediately after the 5th and 10th treatment session, and 1 month later, using frequency of enuresis/week, visual analogue scale (VAS) and quality of life as outcome measures. Resting and active motor thresholds of gastrocnemius muscles were measured before and after the end of sessions. RESULTS: Both treatment and control groups were comparable for baseline measures of frequency of enuresis, and VAS. The mean number of wet nights/week was significantly reduced in patients who received real rSMS. This improvement was maintained 1 month after the end of treatment. Patients receiving real-rSMS also reported an improvement in VAS ratings and quality of life. A significant reduction of resting motor threshold was recorded after rSMS in the real group while no such changes were observed in the sham group. CONCLUSION: These findings suggest that rSMS has potential as an adjuvant treatment for MNE and deserves further study.

Sacral roots stimulation in chronic pelvic pain.

INTRODUCTION: Chronic pelvic pain is a syndrome of chronic non-malignant pain of multifactorial pathophysiology. Perineal, anal and coccygeal pain can be a form of failed-back surgery syndrome or complex regional pain syndrome. Apart from conservative treatment interventional methods are useful in this condition as neurolytic blocks or non-destructive neuromodulation procedures. Peripheral nerve, spinal cord stimulation or sacral stimulation can be applied. AIM: We describe a minimally invasive method of sacral roots stimulation with percutaneous electrodes implanted through the sacral hiatus in the treatment of chronic pelvic pain. MATERIALS AND METHODS: We evaluated a series of nine female patients with pelvic pain treated with sacral roots stimulation in regard of efficacy and complications of this method. RESULTS: Short-term results in all patients were satisfactory with statistically significant improvement (median VAS=9 before surgery) (median VAS=2 after implantation, p=0.001), (median VAS=3 after 6 months, p=0.043). The long-term follow-up revealed less satisfactory result (median VAS=6 after 12 months). High incidence of complications was noted: mainly infection in 3/9 patients. CONCLUSION: Sacral roots stimulation is a non-destructive and minimally invasive neuromodulation method in the treatment of chronic pelvic pain. It can be effective even in the long-term observation but special care is advised to secure aseptic conditions in the implantation and to prevent the infection which leads to removal of the stimulating system.

Effectiveness of neural mobilization in patients with spinal radiculopathy: a critical review.

Spinal radiculopathy (SR) is a multifactorial nerve root injury that can result in significant pain, psychological stress and disability. It can occur at any level of the spinal column with the highest percentage in the lumbar spine. Amongst the various interventions that have been suggested, neural mobilization (NM) has been advocated as an effective treatment option. The purpose of this review is to (1) examine pathophysiological aspects of spinal roots and peripheral nerves, (2) analyze the proposed mechanisms of NM as treatment of injured nerve tissues and (3) critically review the existing research evidence for the efficacy of NM in patients with lumbar or cervical radiculopathy.