Variation in bony landmarks and predictors of success with sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: We assessed variations in sacral anatomy and lead placement as predictors of sacral neuromodulation (SNM) success. Based solely on bony landmarks, we also assessed the accuracy of the 9 and 2 protocol for locating S3. METHODS: This is a retrospective cohort study performed from October 2008 to December 2016 at the University of North Carolina at Chapel Hill. Fluoroscopic images were used to assess sacral anatomy and lead location. Success was defined as >50% symptom improvement after stage I and clinical response at most recent follow-up. RESULTS: Of 249 procedures, 209 were primary implants and 40 were revisions among 187 (89.5%) women and 22 (10.5%) men. Success rate was 83.3% for primary implants and 89.4% for revisions. Success was associated with shorter implant duration (21.3 ± 22.2 vs 33.6 ± 25.8 months), higher body mass index (30.3 ± 7.8 vs 27.6 ± 6.1 kg/m2), and straight vs curved lead (90.5% vs 80.5%) (all p = .05), but not with sacral anatomy or lead placement. In assessing the 9 and 2 protocol, mean distance from coccyx to S3 did not equal 9 cm: 7.4 ± 1.0 vs 7.2 ± 0.8 cm (p = .26), while mean distance from midline to S3 did equal 2 cm: 1.9 ± 0.4 vs 2.0 ± 0.7 cm (p = .37). CONCLUSIONS: Variations in sacral anatomy and lead placement did not predict SNM success. The 2-cm protocol was verified while the 9-cm protocol was not, although neither was predictive of success, which may obviate the need to mark bony landmarks prior to fluoroscopy.

A novel three-dimensional printed guiding device for electrode implantation of sacral neuromodulation.

AIM: The aim was to test the feasibility of a novel three-dimensional (3D) printed guiding device for electrode implantation of sacral neuromodulation (SNM). METHOD: A 3D printed guiding device for electrode implantation was customized to patients' anatomy of the sacral region. Liquid photopolymer was selected as the printing material. The details of the device designation and prototype building are described. The guiding device was used in two patients who underwent SNM for intractable constipation. Details of the procedure and the outcomes are given. RESULTS: With the help of the device, the test needle for stimulation was placed in the target sacral foramen successfully at the first attempt of puncture in both patients. The time to implant a tined SNM electrode was less than 20 min and no complications were observed. At the end of the screening phase, symptoms of constipation were relieved by more than 50% in both patients and permanent stimulation was established. CONCLUSION: The customized 3D printed guiding device for implantation of SNM is a promising instrument that facilitates a precise and quick implantation of the electrode into the target sacral foramen.

Ultrasonography in Acupuncture-Uses in Education and Research.

This study aims to explore the potential use of ultrasound in locating the second posterior sacral foramen acupuncture point, quantifying depth of insertion and describing surrounding anatomical structures. We performed acupuncture needle insertion on a study team member. There were four steps in our experiment. First, the acupuncturist located the acupuncture point by palpation. Second, we used an ultrasound machine to visualize the structures surrounding the location of the acupuncture point and measure the depth required for needle insertion. Third, the acupuncturist inserted the acupuncture needle into the acupuncture point at an angle of 30°. Fourth, we performed another ultrasound scan to ensure that the needle was in the desired location. Results suggested that ultrasound could be used to locate the acupuncture point and estimate the depth of needle insertion. The needle was inserted to a depth of 4.0 cm to reach the surface of the sacral foramen. Based on Pythagoras theorem, taking a needle insertion angle of 30° and a needle insertion depth of 4.0 cm, the estimated perpendicular depth is 1.8 cm. An ultrasound scan corroborated the depth of 1.85 cm. The use of an ultrasound-guided technique for needle insertion in acupuncture practice could help standardize the treatment. Clinicians and students would be able to visualize and measure the depth of the sacral foramen acupuncture point, to guide the depth of needle insertion. This methodological guide could also be used to create a standard treatment protocol for research. A similar mathematical guide could also be created for other acupuncture points in future.

[Exploration of anatomical location of Baliao points of adult female].

Fifteen morphologically and structurally complete sacrum specimens of normotrophic adult females were choosen. Distances between posterior sacral foramina and median sacral crest,and between the cores of adjacent posterior sacral foramina were measured. Then statistical analysis was done so as to provide objective anatomical evidence for the surface localization of Baliao points. The average distance between Shangliao (BL 31) and median sacral crest was (2.08 ± 0.19) cm; and the average distance between Ciliao (BL 32) and median sacral crest was (1.75 ± 0.12) cm; Zhongliao (BL 33), (1.59 ± 0.15) cm; Xialiao (BL 34), (1.56 ± 0.15) cm. And the distance of S1-S2 was (2.36 ± 0.31) cm averagely; S2-S3, (1.98 ± 0.23) cm; S3-S4, (1.71 ± 0.18) cm. It is considered that to locate Baliao points, Ciliao (BL 32) needs to be ascertained firstly.

Surface and boney landmarks for sacral neuromodulation: a cadaveric study.

INTRODUCTION AND HYPOTHESIS: Standard external landmarks have been suggested as a guide for in-office percutaneous nerve evaluation (PNE), but validity of these landmarks has not been assessed. Our objective was to determine whether the standard 9 cm from the tip of the coccyx indicates the position of the S3 sacral foramen and whether other boney landmarks and measurements improved positioning. METHODS: Measurements and distances between external boney landmarks were obtained in 22 embalmed cadavers. Spinal needles were placed 9 cm superior to the coccyx and 2 cm lateral to midline bilaterally. After dissection, internal measurements relating to sacral length, position of S3, and location of the needle in relation to S3 were recorded. Correlations among measured variables were assessed using descriptive statistics. RESULTS: Mean distance from the tip of coccyx to S3 was 9.26 cm (±0.84), from S3 to midline 2.30 cm (±0.2); from needle to S3 1.25 cm, and needle placement was as likely to be placed above or below S3; and S2-S3 and S3-S4 interforamenal distance 1.48 cm (±0.30) and 1.48 cm (±0.24), respectively. Mean distance from S3 to sacroiliac joint (SIJ) was shorter than S2 to SIJ. All associations between external measurements and length from tip of coccyx to S3 were not significant. CONCLUSION: A distance 9 cm from the tip of the coccyx is a reasonable starting landmark for in-office blind PNE. However, given the variability in coccyx length, caution should be taken; also, sensory-motor response is necessary to confirm proper placement.

[Study on the measurement and locating of Baliao points (eight sacral foramina)].

OBJECTIVE: To seek the problems of position, measuring and locating methods of Baliao points (posterior sacral foramina) in modern researches. METHODS: Using Baliao (eight sacral foramina), Shangliao(BL 31), Ciliao(BL 32), Zhongliao(BL 33), Xialiao(BL 34), Dihoukong (posterior sacral foramina), Dikong (sacral foramina) and Digu(sacrum) as the key words, literature in the database of the CNKI from 1957 to 2012 were re trieved and analyzed. RESULTS: Problems were found in the past researches including limited numbers of relative literature, disunity of the measurement targets, complicated terms of indices, disunity of the starting and ending point of measurement, unclear weight of indices, deviation of results, lacking of combination with clinical practice and variety of locating methods. CONCLUSION: Position of Baliao points (eight sacral foramina) are clear. However, the locating methods are blurred and vary a lot. Study on living body has more significance for measurement and researches. Factors of gender, body weight, height and childbearing should also be taken into consideration. Therefore, it is necessary to find a more accurate and easier way of locating.

Third sacral foramina morphometry for sacral neuromodulation.

OBJECTIVE: This study is aimed to define the geometry and location of the human S3 foramen, with respect to bony landmarks visible on ultrasound. METHODS: Computed tomographic (CT) image data from an institutional review board-approved database of de-identified pelvic CT images were analyzed. Points along the S3 foramina and bony sacrum were tagged, and their locations saved. The saved points were mathematically analyzed to determine the geometry and relative location of the S3 foramina with respect to other bony landmarks, specifically the sacral hiatus, and the sacral spinous processes, and the caudad aspect of the bilateral SI joints ("SI line"). Descriptive statistics were used to describe the geometry and aggregate location of the S3 foramina bilaterally. CT data sets were excluded if they had evidence of pelvic bone injury, prior bony fixation, severe osteoporosis, or other deformity. RESULTS: One hundred thirty-three data sets met the inclusion criteria. The SI line was superior to the sacral hiatus for reliable S3 localization. The entire circumference of approximately 14% of the S3 foramina is located cephalad to the SI line. The sagittal angle of trajectory for S3 was approximately 70 degrees relative to the dorsal surface of the sacrum. CONCLUSIONS: Clinical localization of the S3 foramen for sacral neuromodulator needle placement is best obtained when the needle tip is positioned 15 to 25 mm lateral to the sacral spinous processes and 0.0 cm to 25 mm caudad to the SI line, at the level of the dorsal sacrum surface. The findings presented in this study may be applied to improve the efficacy and accuracy of neuromodulator lead placement into the S3 foramen. This study provides rationale for the effectiveness of the crosshair placement technique and demonstrates the best location for needle repositioning when this technique is not initially successful.

Laparoscopic endopelvic sacral implantation of a Brindley controller for recovery of bladder function in a paralyzed patient.

BACKGROUND: A number of techniques are being investigated to accomplish bladder control recovery in paralyzed patients using the neurostimulation, but currently, all techniques are based on the dorsal implantation of the electrodes using a laminectomy. METHODS: On 27 April 2006 we performed a laparoscopic implantation of a Finetech-Brindley bladder controller on the endopelvic sacral roots in a Th8 completely paralyzed woman who had previously undergone the removal of a Brindley controller due to an arachnoiditis after extrathecal implantation with intradural sacral deafferentation. RESULTS: We required about 3.5 h for the entire surgical procedure; no complications occurred and the patients went home on 5th postoperative day. The patient is now able to void empty her bladder and her rectum using the controller without further need for self-catheterisation. CONCLUSIONS: The presented new technique of laparoscopic implantation of electrodes on the endopelvic portion of the sacral nerve roots is an option to be considered in all paralyzed patients with further wish for electrical induced miction/defecation after previous deafferentation.

Influence of axial rotation on chiropractic pelvic radiographic analysis.

OBJECTIVE: The aim of the study is to explore associations between axial (y-axis) rotation of the pelvis and pelvic radiographic measurements. STUDY DESIGN: Descriptive film statistics of an incrementally rotated pelvis and linear regression analysis were performed. METHODS: A phantom pelvic model was incrementally imaged (1 degrees increments) at 40-in source-to-image distance through 10 degrees of axial rotation. Chiropractic line drawing analysis was performed. The chiropractic examiner was blinded to the degree of rotation during the film analysis. Regression analysis was performed between axial rotation and pubic symphysis deviation, sacral width, and innominate and femur head heights. Each measurement corresponds to a chiropractic listing within the Gonstead system. RESULTS: Regression analysis revealed a strong association between the degree of axial rotation and each response variable: pubic symphysis deviation, sacral width, innominate height, and femur head height. The strongest relationship existed between y-axis rotation and pubic symphysis deviation. CONCLUSIONS: Chiropractic pelvic listings are strongly influenced by positioning of the subject. A few degrees of axial rotation may create apparent misalignments of several millimeters.

The development and clinical application of acoustical technique in hip joint.

A non-invasive acoustical system was developed for the measurement of transmission properties of acoustic waves in the hip joints. The instrumentation consisted of three sub-systems. An excitation system employed a vibratory force at the sacrum of the test subjects. A transduction system included a pair of identical microphones installed in the tubes of two stethoscopes, which were placed at the greater trochanters on both sides for picking up the acoustical signals transmitted across the hip joints. The data acquisition and analysis system was a portable signal analyzer with a program of dual channel digital filter for measuring the power of acoustical signal in 1/3-octave frequency bands. 27 normal adults, 20 normal pre-school children and 40 normal neonates were randomly selected for testing. Coherence function (CF) and discrepancy (D) was measured during the testing. Results from the three groups showed that there was a high coherence of the signals (CF > 0.9) and a small discrepancy (D < 3 dB) between bilateral hips in the frequency range of 200-315 Hz. For normal neonates, there was a wider frequency range of 160-315 Hz in which the acoustical signals maintained a high coherence (CF > 0.93) and a smaller discrepancy (D < 2 dB) was observed. This study showed that the development of the acoustical technique provided a practical method with objective parameters. The results obtained in this study can offer a baseline for further investigation of hip disorders particularly those related to structural abnormalities of the hip.

The development and clinical application of acoustical technique in hip joint / 华中科技大学学报（医学）（英德文版）

A non-invasive acoustical system was developed for the measurement of transmission properties of acoustic waves in the hip joints. The instrumentation consisted of three sub-systems. An excitation system employed a vibratory force at the sacrum of the test subjects. A transduction system included a pair of identical microphones installed in the tubes of two stethoscopes, which were placed at the greater trochanters on both sides for picking up the acoustical signals transmitted across the hip joints. The data acquisition and analysis system was a portable signal analyzer with a program of dual channel digital filter for measuring the power of acoustical signal in 1/3-octave frequency bands. 27 normal adults, 20 normal pre-school children and 40 normal neonates were randomly selected for testing. Coherence function (CF) and discrepancy (D) was measured during the testing. Results from the three groups showed that there was a high coherence of the signals (CF > 0.9) and a small discrepancy (D 0.93) and a smaller discrepancy (D < 2 dB) was observed. This study showed that the development of the acoustical technique provided a practical method with objective parameters. The results obtained in this study can offer a baseline for further investigation of hip disorders particularly those related to structural abnormalities of the hip.

Modified techniques of S3 foramen localization and lead implantation in S3 neuromodulation.

INTRODUCTION: We describe a reproducible and less invasive surgical approach to sacral neuromodulation (InterStim Therapy) in the treatment of voiding dysfunction. Twenty patients underwent modified lead implantation (mean operative time 45 minutes) without any difficulties or complications, with a mean follow-up of 8 months (range 1 to 14).Technical Considerations. The highlights of these modifications include (a) fluoroscopy to localize the S3 foramen; (b) paramedian incision; (c) use of a cutoff S3 finder needle and a 14-gauge Angiocath to direct permanent lead into the S3 foramen without dissection; (d) use of lateral fluoroscopy to determine the depth of the Angiocath insertion; and (e) anchoring the lead to the lumbodorsal fascia (superficial to the sacral periosteum) using a moveable lead anchor system. These modifications simplify and minimize the invasiveness of this therapy without compromising the efficacy. CONCLUSIONS: Because of the simplicity of these modifications, we are currently using an implanted lead, rather than the temporary percutaneous lead, to assess patients' clinical response before implanting a pulse generator.

Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study.

Despite the paucity of research into the reliability of static palpation, it is still employed extensively as a diagnostic tool by manual medicine practitioners. This study tested the inter- and intra-examiner agreement of ten senior osteopathic students using static palpation on ten asymptomatic subjects. Four assessments of the posterior superior iliac spine (PSIS), sacral sulcus (SS), and the sacral inferior lateral angle (SILA) on every subject by all examiners resulted in 1200 assessments in total. Kappa (Kg) yielded intra-examiner agreement that ranged between less-than-chance to substantial for the SILA (Kg=-0.05 to 0.69; mean Kg=0.21), and slight to moderate for the PSIS (Kg=0.07 to 0.58; mean Kg=0.33) and the SS (Kg=0.02 to Kg=0.60; mean Kg=0.24), with 50% significant beyond the 0.05 level. Inter-examiner agreement was slight (PSIS Kg=0.04; SILA Kg=0.08; SS Kg=0.07) and significant at the 0.01 level. Intra-examiner agreement was greater than inter-examiner agreement, which was consistent with existing palpation reliability studies. The poor reliability of clinical tests involving palpation may be partially explained by error in landmark location.

Pruebas científicas de la movilidad del cráneo / Scientific test of cranial mobility

La osteopatía craneal no debe ser basada sobre el misticismo; el famoso movimiento respiratorio primario (MRP) no existe. Las pruebas científicas demostrando que existe un micromovimiento a nivel de las suturas craneales son numerosas, así como sobre las imposibilidades de que existe un MRP. La hipótesis más probable es que el motor del sistema cráneo sacro sea la respiración costal que a través de las tensiones fasciales y de la columna vertebral mueve el sistema craneal, vertebral y la pelvis. Las explicaciones del cómo funcionan las técnicas osteopáticas craneales a través de la neurofisiología ya existen, de la misma manera que se conocen las repercusiones neurológicas de las disfunciones suturales craneales. Este articulo propone además de una teoría nueva para explicar el mecanismo craneosacro, una lista de artículos científicos publicados sobre el tema (AU)

Cranial osteopathy should not be based on mysticism, they is not such a thing as famous primary respiratory movement (MRP), doesn't exist. The scientific studies demonstrating that a micro movement exists in the cranial sutures are numerous, as well as exist impossibilities for reality of the MRP. The hypothesis most acceptable is that the motor of the cranio-sacral system is the costal respiration that through the fasciales tensions and the spine moves the cranial, vertebral system and pelvis. The explanations of how are efficient cranial osteopathic techniques through the neuro-physiology already exist, in the same way that the neurological repercussions of the cranial sutures dysfunctions are known. This paper proposes besides a new theory to explain the cranio-sacral mechanism, a list of scientific articles published on the topic (AU)

[The enlarged retrorectal space--indicative of specific pathology or only unspecific symptom of disease in the true pelvis? (author's transl)]. / Der erweiterte Retrorectalraum--ein sicher pathologisches oder nur unspezifisches Zeichen einer Erkrankung im kleinen Becken?

The retrorectal space was measured on the lateral view of the rectum during double contrast barium enema examination in 300 patients in whom no abnormality of the rectum, sacrum or in the true pelvis was demonstrated clinically or radiographically. The measurement obtained is the distance between posterior wall of the rectum and the anterior surface of the sacrum between S2 and S5. The measurements at S5 are considered most accurate, since at this level the rectum will be positively in midline. The normal width at S5 is between 0.2 and 1.5 cm. In connection with other symptoms, a distance between 1.5 and 2 cm should be regarded as suspicious and above 1 cm as definitely abnormal, as was demonstrated in 95 cases with diffuse and localized enlargement of the retrorectal space. An abnormal measurement of greater than 2 cm however is an unspecific symptom and should not by itself be considered indicative of specific pathology, but rather should lend supporting evidence to other abnormal findings in the true pelvis.