Elimination of Lumbar Plexus Injury by Changing the Entry Point and Traction Direction of the Psoas Major Muscle in Transpsoas Lateral Lumbar Spine Surgery.

Background and Objectives: The lateral approach is commonly used for anterior column reconstruction, indirect decompression, and fusion in patients with lumbar degenerative diseases and spinal deformities. However, intraoperative lumbar plexus injury may occur. This is a retrospective comparative study to investigate and compare neurological complications between the conventional lateral approach and a modified lateral approach at L4/5. Materials and Methods: Patients with a lumbar degenerative disease requiring single-level intervertebral fusion at L4/5 were included and categorized into group X and group A. Patients in group X underwent conventional extreme lateral interbody fusion, while those in group A underwent a modified surgical procedure that included splitting of the anterior third of the psoas muscle, which was dilated by the retractor on the anterior third of the intervertebral disc. The incidence of lumbar plexus injury, defined as a decrease of ≥1 grade on manual muscle testing of hip flexors and knee extensors and sensory impairment of the thigh for ≥3 weeks, on the approach side, was investigated. Results: Each group comprised 50 patients. No significant between-group differences in age, sex, body mass index, and approach side were observed. There was a significant between-group difference in intraoperative neuromonitoring stimulation value (13.1 ± 5.4 mA in group X vs. 18.5 ± 2.3 mA in group A, p < 0.001). The incidence of neurological complications was significantly higher in group X than in group A (10.0% vs. 0.0%, respectively, p < 0.05). Conclusions: In our modified procedure, the anterior third of the psoas muscle was entered and split, and the intervertebral disc could be reached without damaging the lumbar plexus. When performing lumbar surgery using the lateral approach, lumbar plexus injury can be avoided by following surgical indication criteria based on the location of the lumbar plexus with respect to the psoas muscle and changing the transpsoas approach to the intervertebral disc.

Surgical Treatment of Vertical Shear Pelvic Fracture Associated with a Lumbosacral Plexus Injury through the Lateral-Rectus Approach: Surgical Techniques and Preliminary Outcomes.

OBJECTIVE: To examine the surgical techniques and preliminary outcomes of the lateral rectus approach (LRA) for treating vertical shear (VS) pelvic fracture associated with lumbosacral plexus (LSP) injury. METHODS: This study was a retrospective trial. From August 2010 to October 2017, 29 patients with VS pelvic fractures involving LSP injury who were treated with the LRA were included in this study. The patients were 18-61 years old, with a mean age of 36.2 years. All patients underwent neurolysis, open reduction, and internal fixation (ORIF) through the LRA. The fracture reduction was evaluated using the Matta criteria, and the neural recovery was evaluated by muscle strength grading proposed by the British Medical Research Council (BMRC). RESULTS: All 29 patients underwent the surgery successfully. The mean operating time was 155.2 ± 32.1 min (range: 105-220 min). The mean operative blood loss was 1021.4 ± 363.4 mL (range: 400-2000 mL). All patients were followed-up for at least 24 months (mean, 32.8 ± 13.5 months; range: 24-96 months). According to the Matta criteria, there were 17 excellent cases, nine good cases, and three fair cases in 29 patients. The ratio of excellent-to-good cases was 89.66%. According to the criteria of the Nerve Injuries Committee of the British Medical Research Council (BMRC), the recovery of nerve and muscle strength achieved to M5 (full recovery of neurological symptoms) was 14 cases, M4 (fine recovery of neurological symptoms), seven cases; M1, M2, and M3 (partial recovery of neurological symptoms), five cases, and M0 (no recovery of neurological symptoms), three cases. CONCLUSIONS: LRA is a safe and feasible surgical approach for treating VS pelvic fractures with LSP injury, which can be used to perform nerve exploration and release from the front, reduce the fracture, and fix it with the anterior iliac plates and/or sacroiliac screws.

The clinical value of using magnetic resonance contrast-enhanced three-dimensional nerve view in the diagnosis and management of sacral fracture accompanied by sacral plexus injury.

BACKGROUND: The treatment of sacral fractures accompanied by nerve injury is complex and often leads to an unsatisfactory prognosis and poor quality of life in patients. OBJECTIVE: The present study aimed to investigate the clinical value of using 3.0T magnetic resonance contrast-enhanced three-dimensional (MR CE-3D) nerve view magnetic resonance neurography (MRN) in the diagnosis and management of a sacral fracture accompanied by a sacral plexus injury. METHODS: Thirty-two patients with a sacral fracture accompanied by a sacral plexus injury, including 24 cases of Denis spinal trauma type II and 8 cases of type III, were enrolled in the study. All patients had symptoms or signs of lumbosacral nerve injury, and an MRN examination was performed to clarify the location and severity of the sacral nerve injury. Segmental localization of the sacral plexus was done to indicate the site of the injury as being intra-spinal (IS), intra-foraminal (IF), or extra-foraminal (EF), and the severity of the nerve injury was determined as being mild, moderate, or severe. Surgical nerve exploration was then conducted in six patients with severe nerve injury. The location and severity of the nerve injury were recorded using intra-operative direct vision, and the results were statistically compared with the MRN examination results. RESULTS: MRN showed that 81 segments had mild sacral plexus injuries (8 segments of IS, 20 segments of IF, 53 segments of EF), 78 segments had moderate sacral plexus injuries (8 segments of IS, 37 segments of IF, and 33 segments of EF), and 19 segments had severe sacral plexus injuries (7 segments of IS, 9 segments of IF, and 3 segments of EF). The six patients who underwent surgery had the following intra-operative direct vision results: 3 segments of moderate injury (IF) and 20 segments of severe injury (7 segments of IS, 10 segments of IF, 3 segments of EF). There was no statistically significant difference in the results between the intra-operative direct vision and those of the MRN examination (p> 0.05). CONCLUSION: MR CE-3D nerve view can clearly and accurately demonstrate the location and severity of sacral nerve injury accompanied by a sacral fracture, and has the potential for being the first choice of examination method for this kind of injury, which would be of important clinical value.

Effects of thigh extension on the position of the femoral nerve: application to prone lateral transpsoas approaches to the lumbar spine.

Some authors have suggested that thigh extension during the prone lateral transpsoas approach to the lumbar spine provides the theoretical advantage of providing posterior shift of the psoas muscle and plexus and is responsible for its lower rates of nerve injury. We aimed to elucidate the effects of surgical positioning on the femoral nerve within the psoas muscle via a cadaveric study. In the supine position, 10 fresh frozen adult cadavers had a metal wire secured to the pelvic segment of the femoral nerve and then extended proximally along with its L2 contribution. Fluoroscopy was then used to identify the wires on the femoral nerves in a neutral position and with the thigh extended and flexed by 25 and 45°. Additionally, a lateral incision was made in the anterolateral abdominal wall to mimic a lateral transpsoas approach to the lumbar spine, and measurements were made of the amount of movement in the vertical plane of the femoral nerve from neutral to then 25 and 45° of thigh flexion and extension. On fluoroscopy, the femoral nerves moved posteriorly at a mean of 10.1 mm with thigh extension. Femoral nerve movement could not be detected at any degree of this range of flexion of the thigh. Extension of the thigh to about 30° can move the femoral nerve farther away from the dissection plane by approximately one centimeter. This hip extension not only places the femoral nerve in a more advantageous position for lateral lumbar interbody fusion procedures but also helps to promote accentuation of lumbar lordosis.

Lumbosacral plexopathy due to pelvic hematoma after extracorporeal membrane oxygenation: A case report.

RATIONALE: Peripheral nerve injury related to vascular complications associated with extracorporeal membrane oxygenation (ECMO) is perhaps underappreciated. Compared to the well-described central nervous system complications of ECMO, brachial plexopathy and lumbosacral plexopathy have rarely been reported. We report this case to heighten awareness of lumbosacral plexus injury due to pelvic hematoma formation after ECMO. PATIENT CONCERNS: A 53-year-old woman developed a large pelvic hematoma with significant mass effect on intrapelvic structures after receiving lifesaving venoarterial ECMO for cardiogenic shock following a cardiac arrest. During her hospital course, she developed bilateral foot drop that was attributed to critical illness. Her lack of neurological recovery after 6 months prompted referral to neuromuscular medicine for consultation. DIAGNOSIS: The patient was retrospectively diagnosed with bilateral lumbosacral plexopathy due to the large pelvic hematoma. INTERVENTION: Electromyography/nerve conduction study (EMG/NCS) obtained at the time of referral to neuromuscular medicine localized her neurological deficits to the bilateral lumbosacral plexus and demonstrated no volitional motor unit action potentials in her lower leg muscles. OUTCOMES: The patient had minimal recovery of strength at the level of the ankles but was ambulatory with solid ankle-foot orthoses due to spared proximal lower extremity strength. Unfortunately, the absence of any volitionally activated motor unit action potentials in her lower leg muscles on EMG performed 6 months after the initial injury was a poor prognostic indicator for successful reinnervation and future neurological recovery. LESSONS: Neurological deficits occurring during the course of administration of ECMO require accurate localization. Neurology consultation and/or EMG/NCS may be useful if localization is not clear. Lesions localizing to the lumbosacral plexus should prompt radiographic evaluation with computed tomography of the abdomen and pelvis. Hemostasis of a retroperitoneal hematoma may be achieved with embolization. However, if neurological deficits do not improve, surgical consultation for hematoma evacuation may be warranted.

Postmortem evaluation of neuromuscular damages more extensive than the surgical intervention area after iliac crest bone graft.

Several complications may occur following iliac bone grafting, one of the common sites for autologous bone harvesting. Of these, it is difficult to localize the damage in neurological complications due to the presence of several nerves in a similar distribution area with variations among individuals. To minimize these complications, conventional clinical anatomical studies using normal human cadavers have estimated the theoretical neurological damage area corresponding to the surgical intervention area. We report a case of neuromuscular damage in a 93-year-old woman who had an iliac crest defect after a bone graft, based on the virtual and physical dissections with histological confirmations.In this study, the patient was confirmed to have severe neuromuscular complications with major complications including a hernia protruding through the iliac defect. One of the two ilioinguinal nerves was extracted with the hernia sac through the iliac defect, and its distal part was completely damaged. The iliohypogastric nerve, which was far from the defect foramen, also showed remarkable fibrosis and demyelination, affected by the degeneration of the transversus abdominis muscles.The present anatomical findings show that the area of eventual neuromuscular damage should be estimated to larger than the conventionally predicted area of direct nerve damage, which is usually concomitant with the surgical intervention area.

Enhanced MR neurography of the lumbosacral plexus with robust vascular suppression and improved delineation of its small branches.

PURPOSE: To evaluate whether gadolinium enhanced 3D SPACE STIR sequence technique increases the visualization of the lumbosacral plexus (LSP) and its small branches. METHODS: A retrospective study was performed on 24 patients who had underwent 3D SPACE STIR sequences scan with and without the administration of gadolinium contrast. In this study, we focused on the healthy sides of the LSP and its branches in each patient. The contrast ratio (CR), contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were objectively calculated by two experienced radiologists. The subjective visualization scores of the branches that were vitally important to therapeutic decision-making including femoral nerves, obturator nerves, lumbosacral trunks, superior gluteal and extra-pelvic sciatic nerves, were assessed using post-processing images. RESULTS: Of the 24 subjects, all LSP nerve roots, femoral nerves, lumbosacral trunks and sciatic nerves were illustrated on both contrast-enhanced and non-contrast images. The enhanced images were found to have higher nerve to vein CNRs compared to non-contrast images. Compared to non-contrast images, the CRs of nerves versus surrounding fat tissues, bones, veins and muscles were improved in contrast-enhanced images, while the SNRs were better but not significantly so. Targeted maximum intensity projection (MIP) nerves including femoral, obturator, superior gluteal and extra-pelvic sciatic nerves obtained significantly higher subjective scores when gadolinium was administered. CONCLUSIONS: The gadolinium enhanced 3D SPACE STIR sequence provided superior vascular suppression, resulting in increased conspicuity of LSP and its small branches. Altogether, this shows great potential for therapeutic decision-making in traumatic LSP lesions cases.

Factors associated with gait outcomes in patients with traumatic lumbosacral plexus injuries.

PURPOSE: Lumbosacral plexus injuries usually occur in patients with severe, multiple traumas requiring intensive care, affecting gait function. The purpose of the present study was to identify the initial factors associated with gait outcome in lumbosacral plexus injuries caused by traumas. METHODS: We retrospectively identified 664 patients with pelvic fractures caused by trauma between 2006 and 2017. The lumbosacral plexus injuries were electrodiagnostically confirmed in 30 patients (4.5%). Demographic, injury-related, fracture-related and electrodiagnostic factors were compared between patients with long-term unassisted gait outcomes to those with assisted gait outcomes, with an average of 27 months elapsing after the trauma. RESULTS: Eleven patients (36.7%) remained in the assisted gait group during the follow-up period. Complex pelvic trauma, rather than the severity of trauma to the entire body, was associated with a poor gait outcome. Among the various causes of injury, pedestrians struck by vehicles were associated with assisted gait outcomes. The number of anatomic locations involved in pelvic fractures, pelvic ring instability by Tile classification, and the proportion of unstable sacral fractures were higher in patients with assisted gait outcomes compared with those having unassisted gait outcomes. Weaknesses in the initial hip extensor, knee flexor, ankle dorsiflexor and ankle plantar flexor were observed significantly more often in patients with assisted gait outcomes. The Dumitru and Wilbourn's scale of the anterior and posterior sacral plexus was significantly higher in the assisted gait group. CONCLUSIONS: Gait outcome after lumbosacral plexus injury is associated with the range and stability of the pelvic fracture and the severity of the anterior and posterior sacral plexus injury. Poor gait outcome was associated with the severity of the trauma to the pelvis rather than that to the entire body.

Identifying Plasma Derived Extracellular Vesicle (EV) Contained Biomarkers in the Development of Chronic Neuropathic Pain.

Research into potentially novel biomarkers for chronic pain development is lacking. microRNAs (miRNAs) are attractive candidates as biomarkers due to their conservation across species, stability in liquid biopsies, and variation that corresponds to a pathologic state. miRNAs can be sorted into extracellular vesicles (EVs) within the cell and released from the site of injury. EVs transfer cargo molecules between cells thus affecting key intercellular signaling pathways. The focus of this study was to determine the plasma derived EV miRNA content in a chronic neuropathic pain rat model. This was accomplished by performing either spinal nerve ligation (SNL; n = 6) or sham (n = 6) surgery on anesthetized male Sprague-Dawley rats. Mechanosensitivity was assessed and plasma derived EV RNA was isolated at baseline (BL), day 3, and 15 postnerve injury. EV extracted small RNA was sequenced followed by differentially expressed (DE) miRNAs and gene target enrichment/signaling pathway analysis performed using R packages and TargetScan/Ingenuity pathway analysis (IPA), respectively. Seven of the DE miRNAs were validated by Reverse Transcription-quantitative Polymerase Chain Reaction (RT-qPCR). The data indicated that SNL rats displayed a time-dependent threshold reduction in response to evoked stimuli from day 3 to day 15 postnerve injury. The data also revealed that 22 and 74 miRNAs at day 3 and 15, respectively, and 33 miRNAs at both day 3 and 15 were uniquely DE between the SNL and sham groups. The key findings from this proposal include (1) the majority of the DE EV miRNAs, which normally function to suppress inflammation, were downregulated, and (2) several of the plasma derived DE EV miRNAs reflect previously observed changes in the injured L5 nerve. The plasma derived DE EV miRNAs regulate processes important in the development and maintenance of neuropathic pain states and potentially serve as key regulators, biomarkers, and targets in the progression and treatment of chronic neuropathic pain. PERSPECTIVE: This article describes the DE miRNA content of plasma derived EVs, comparing neuropathic pain to normal conditions. This data indicates that EV miRNAs may be important in nociception and may also serve as biomarkers for chronic pain. These results encourage further research on EV miRNAs in chronic neuropathic pain sufferers.

[Reconstruction of Lower Extremity Palsy after Pelvic Fractures with the Muscle Transfers]. / Rekonstrukce paréz dolní koncetiny po zlomeninách pánve svalovými transfery.

PURPOSE OF THE STUDY The prevalence of nerve structure injuries accompanying pelvic and acetabular fractures is stated to be 5-25 %, with most frequent injuries to motor nerve structures associated with fractures of the posterior wall of the acetabulum. Prognostically worse outcomes of regeneration are documented mainly in iatrogenic, intraoperative injuries to nerve structures. This study aims to document the functional effect of muscle transfers restoring the movement of lower extremities with irreversible nerve lesion caused by the pelvic and acetabular fracture. MATERIAL AND METHODS A total of 18 patients with irreversible palsy of lower extremities in L4-S1 segments underwent a reconstruction surgery in the period 2006-2016, of whom 13 patients with the mean age of 42 (21-79) years arrived for a follow-up. The group included 10 patients with the loss of function of peroneal portion of the sciatic nerve, one patient sustained femoral nerve lesion and two patients suffered complete sciatic nerve lesion (both the peroneal and tibial portion). The patients were evaluated at the average follow-up of 77 (24-129) months after the reconstruction surgery. The average time interval from pelvic fracture to reconstruction by muscle transfer was 47 (18-151) months. Due to a wide spectrum of functional damage, the patients were evaluated in terms of the overall effect of the reconstruction surgery on the activities of daily living using the LEFS (The Lower Extremity Functional Scale). The surgical techniques used transposition of tensor fascie latae for femoral nerve lesion, transposition of tibialis posteriormuscle for palsy of the peroneal division of the sciatic nerve and tenodesis of tibialis anterior tendon and peroneus longustendon for the palsy of the peroneal and tibial portion of sciatic nerve. RESULTS The effect of movement restoration on daily living evaluated using the LEFS achieved 65 points (53-79) which is 85% of the average value of LEFS in healthy population. The transposition of active muscles tibialis posterior and tensor fasciae latae resulted in all the patients in active movement restoration. A loss of correction of foot position following the performed tenodesis of the paralysed tibialis anterior muscle was observed in one patient, with no significant impact on function. No infection complication was reported in the group. In 78% of patients the intervention was performed as day surgery. DISCUSSION There is a better prognosis for restoration in incomplete nerve lesion than in complete lesions and also in the loss of sensation than in the loss of motor function. The mini-invasive stabilisation of pelvic ring according to literature does not increase the risk of nerve lesions, while on the other hand a higher incidence of femoral nerve damage by INFIX fixator is documented. The type of muscle transfer is selected based on the availability of active muscles suitable for transposition and also with respect to functional requirements of the patient. CONCLUSIONS Irreversible palsy of lower extremity after the pelvic fracture is easily manageable as to the restoration of function. Surgical interventions using the preserved active muscles to restore the lost movement should be a component part of comprehensive surgical care for patients who sustained a pelvic fracture and should be performed centrally at a centre availing of comprehensive expertise. Key words: nerve lesion, tendon transfer, acetabulum, pelvis, fracture.

Outcome After Extreme Lateral Transpsoas Approach: Corpectomies Versus Interbody Fusion.

INTRODUCTION: The lateral transpsoas approach (LTPA) has gained popularity in thoracolumbar spine surgery procedures; however, there is an insufficient amount of data pertaining to motor and sensory complications that arise when a corpectomy is performed through the LTPA approach. METHODS: Patients who underwent a corpectomy through a LTPA at a single institution between 2006 and 2016 were analyzed. Demographics, neurological outcomes, and complications were recorded. The minimum follow-up was 6 months. Univariate analysis was performed to compare demographics, surgical characteristics, complications, and outcome scores. To compare categorical variables, the χ2 test was used. For continuous outcomes, simple linear regression was used. Statistical significance was set at P < 0.05. RESULTS: A total of 166 patients were included. The patients were divided into 2 groups; LTPA without corpectomy (n = 112) versus LTPA with corpectomy (n = 54). Patients without corpectomy showed a significantly lower rate of postoperative infections compared with patients with corpectomy (3.6% vs. 22.2%; P < 0.000). A higher percentage of postoperative complications was found in patients with corpectomy (31.5% vs. 13.4%; P = 0.006). The rate of neurologic complications at the 6-month follow-up and the reoperation rate (22.7% vs. 32.4%; P = 0.256) were higher in the corpectomy group (8.9% vs. 7.4%; P = 0.741), no significant difference was found between the groups. CONCLUSION: Patients who underwent an LTPA corpectomy have a higher risk to suffer from postoperative complications. The results at the 6-month follow-up did not significantly differ between the groups.

Intrapartum lesions to the lumbar portion of the lumbosacral plexus: an anatomical review

The lumbosacral plexus is formed by the ventral rami of L2-S3 and provides sensory and motor branches to the lower extremity. The spatial orientation of the lumbar portion of the plexus above the pelvic brim leaves it particularly susceptible to intrapartum injury by the fetal head. Such lesions are subdivided into two groups: upper lumbar plexus (L1-L4) and lumbosacral trunk (L4-L5). Given the root levels involved, upper lumbar plexus lesions produce symptoms suggestive of iliohypogastric, ilioinguinal, genitofemoral, femoral, and obturator neuropathies or L4 radiculopathies. Alternatively, involvement of the lumbosacral trunk can imitate a common fibular (peroneal) neuropathy or L5 radiculopathy. This symptomatic overlap with various neuropathies and radiculopathies, makes diagnosis of such lesions particularly challenging. To assist in the clinical diagnosis of intrapartum lumbosacral plexopathies, we provide an overview of the motor, sensory, and reflex deficits associated with such lesions and establish the clinical profile of such patients by presenting case studies from the literature of lumbosacral plexopathies. Only cases from the literature involving women who delivered via cesarean section are explored to isolate the presentation of these lesions from injuries related to birth trauma.Based on this overview, we offer differential diagnostic tools which can be utilized to aid in the identification and subsequent treatment of intrapartum lesions to the lumbar portion of the lumbosacral plexus

No disponible

Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies.

PURPOSE: Patients who undergo inguinal hernioplasty may suffer from persistent postoperative pain due to inguinal nerve injuries. The aim of this systematic review and meta-analysis was to provide comprehensive data on the prevalence (identification rates), anatomical characteristics, and ethnic variations of the ilioinguinal (IIN), the iliohypogastric (IHN) and the genital branch of the genitofemoral (GNF) nerves. METHODS: The systematic literature search was conducted using the PubMed, Scopus and Web of Science databases. RESULTS: A total of 26 articles (5265 half-body examinations) were included in this study. The identification rate of the IIN was 94.4% (95% CI 89.5-97.9) using a random-effects model. Unweighted multiple regression analysis showed that study sample size (ß = - 0.74, p = .036) was the only statistically significant predictor of lower prevalence. The identification rates of the IHN and GNF was 86.7% (95% CI 78.3%-93.3%) and 69.1% (95% CI 53.1%-83.0%) using a random-effects model, respectively. For those outcomes, a visual analysis of funnel and Doi plots indicated irregularity and provided evidence that larger studies tended to have lower identification rates. In terms of the synthesis of anatomical reference points, there was a large and statistically significant amount of heterogeneity for most outcomes. CONCLUSIONS: The identification rates of the inguinal nerves in our study were lower than reported in literature. The lowest was found for GNF, suggesting that this nerve was the most difficult to identify. Knowledge regarding the anatomy of the inguinal nerves can facilitate their proper identification and reduce the risk of iatrogenic injury and postoperative pain.

Differential diagnosis of knee pain following a surgically induced lumbosacral plexus stretch injury. A case report.

Background and Purpose: Knee joint biomechanics requires an understanding of lower extremity (LE) segmental interactions. In some cases, knee pain may arise as a result of altered LE biomechanics; while in other cases, knee pain may stem from other causes, such as a peripheral nerve injury. Case Description: A 33-year-old woman presented via direct access for physical therapist (PT) examination with a chief complaint of left knee pain. The day after undergoing a dilation and curettage (D&C) procedure the patient had an acute onset of gait dysfunction. Over the next few days, the patient developed left anterior knee pain (7/10 at worst) in addition to a significant change in physical functioning (Lower Extremity Functional Scale [LEFS] 38/80). Physical examination revealed left LE weakness, altered sensation, and an absent Achilles deep tendon reflex. Outcomes: The patient's presentation was consistent with a lumbosacral plexus stretch injury, with S1 being most affected. A physiatrist was consulted and recommended initiating PT treatment with bi-weekly re-examination. The 6-week (14 visits) re-examination revealed abolished left knee pain and improved physical functioning (LEFS 66/80). Conclusion: Stretch injuries are a known complication of lithotomy positioning. Knowledge of this and the addition of a thorough examination allowed the PT to identify the possible cause of the patient's abrupt onset of left LE dysfunction. Regardless of mode of patient access, screening for referral is crucial and may include referral or, as in this case, consultation with other professionals.

Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial / Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

Abstract Background Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. Methods Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. Results Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p = 0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. Conclusions Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Resumo Justificativa A isquemia miocárdica perioperatória é comum em pacientes submetidos à cirurgia de fratura de quadril. Nosso objetivo foi avaliar a eficácia do bloqueio perioperatório contínuo do plexo lombar na redução do risco de eventos cardíacos isquêmicos em pacientes idosos submetidos à cirurgia para fraturas de quadril, expresso como uma redução de eventos isquêmicos por indivíduo. Métodos Pacientes com mais de 60 anos de idade, ASA II-III com fatores de risco para ou com doença coronariana conhecida foram incluídos neste estudo controlado e randomizado. Os pacientes foram aleatorizados para analgesia convencional usando analgésicos opioides para administração de analgesia intravenosa controlada pelo paciente (Intravenous Patient-Controlled Analgesia - IVPCA) ou analgesia contínua com o bloqueio do Plexo Lombar (PL), ambas iniciadas no pré-operatório e mantidas até o terceiro dia de pós-operatório. Monitoração contínua de ECG com análise do segmento ST foi registrada. Enzimas cardíacas seriadas e escores de dor foram registrados durante todo o período. Medimos a incidência de eventos isquêmicos por indivíduo registrados com monitoração contínua do segmento ST via Holter. Resultados Trinta e um pacientes (IVPCA 14, PL 17) foram incluídos. Não houve eventos cardíacos sérios durante o período de observação. O número de eventos isquêmicos registrados por sujeito durante o período de observação foi de seis no grupo PL e três no grupo IVPCA. Essa diferença não foi estatisticamente significativa (p = 0,618). Não houve diferenças estatisticamente significativas no número de casos com aumento dos valores de troponina no perioperatório (três casos no grupo LP e um caso no grupo IVPCA) ou em termos de escores de dor. Conclusões O uso da analgesia perineural contínua comparado ao da analgesia sistêmica convencional não modifica a incidência de eventos isquêmicos cardíacos no período perioperatório de pacientes idosos com fratura de quadril.

Femoral nerve and lumbar plexus injury after minimally invasive lateral retroperitoneal transpsoas approach: electrodiagnostic prognostic indicators and a roadmap to recovery.

Injury to the lumbosacral (LS) plexus is a well-described complication after lateral retroperitoneal transpsoas approaches to the spine. The prognosis for functional recovery after lumbosacral plexopathy or femoral/obturator neuropathy is unclear. We designed a retrospective case-control study with patients undergoing one-level lateral retroperitoneal transpsoas lumbar interbody fusion (LLIF) between January 2011 and June 2016 to correlate electrodiagnostic assessments (EDX) to physiologic concepts of nerve injury and reinnervation, and attempt to build a timeline for patient evaluation and recovery. Cases with post-operative obturator or femoral neuropathy were identified. Post-operative MRI, nerve conduction studies (NCS), electromyography (EMG), and physical examinations were performed at intervals to assess clinical and electrophysiologic recovery of function. Two hundred thirty patients underwent LLIF. Six patients (2.6%) suffered severe femoral or femoral/obturator neuropathy. Five patients (2.2%) had immediate post-operative weakness. One of the six patients developed delayed weakness due to a retroperitoneal hematoma. Five out of six patients (83%) demonstrated EDX findings at 6 weeks consistent with axonotmesis. All patients improved to at least MRC 4/5 within 12 months of injury. In conclusion, neurapraxia is the most common LS plexus injury, and complete recovery is expected after 3 months. Most severe nerve injuries are a combination of neurapraxia and variable degrees of axonotmesis. EDX performed at 6 weeks and 3, 6, and 9 months provides prognostic information for recovery. In severe injuries of proximal femoral and obturator nerves, observation of proximal to distal progression of small-amplitude, short-duration (SASD) motor unit potentials may be the most significant prognostic indicator.

Pain areas and mechanosensitivity in patients with chronic pelvic pain syndrome: a controlled clinical investigation.

OBJECTIVE: A thorough clinical assessment including physical examination is crucial in a diagnostic work-up, including in patients with chronic pelvic pain syndrome (CPPS). This study investigated the prevalence of pain areas and the mechanosensitivity of peripheral nerves in patients with CPPS and compared the findings with a healthy control group. MATERIALS AND METHODS: Healthy volunteers and patients diagnosed with CPPS were assessed with physical examinations and neurodynamic testing. RESULTS: The CPPS group (n = 26) and the control group (n = 28) showed no statistical differences between males and females for age and body mass index (Mann-Whitney U test). The patients in the CPPS group were significantly older and had a significantly higher weight compared to controls. Healthy volunteers did not show any pain area or mechanosensitivity of the examined peripheral nerves of the lumbosacral plexus. Patients with CPPS showed a variety of pain from different musculoskeletal origins. Neurodynamic testing demonstrated significant mechanosensitivity in at least one nerve of the lumbosacral plexus in 88% of the patients with CPPS, suggesting minor nerve injuries. Pudendal nerve mechanosensitivity was found in 85% of patients, while 42% had multiple nerves involved. Unilateral or bilateral pudendal channel palpatory pain was present in 62% of the CPPS group and not in controls. CONCLUSIONS: This study shows musculoskeletal pain and a high prevalence of minor nerve injuries in CPPS patients, indicating the presence of abnormal impulse generation sites that can help in understanding the clinical picture in CPPS patients and guiding their treatment.

Rectal foreign body insertion as a rare cause of persistent lumbosacral plexus injury.

Rectal foreign body insertion is a common condition in emergency surgery, which often requires surgical intervention. Here we report a clinical case of rectal foreign body insertion as a rare cause of persistent lumbosacral plexus injury. A 72-year-old man presented to the emergency department complaining of acute bilateral paraplegia with loss of sensation in both legs, as well as total urinary retention. The patient underwent abdominal computed tomography, which showed a rectal foreign body measuring 13 × 11.5 × 10 cm in the lower abdomen and pelvis. Extraluminal assistance through a median laparotomy was required after unsuccessful attempts at transanal recovery alone. After removal of the foreign body, the rectal wall and anorectal sphincter were massively dilated, with severe bruising of the rectal mucosa on proctoscopy. A protective loop-ileostomy was performed. The sacral plexus is located posteriorly in the pelvis. Physiologically, the nerves are well protected by surrounding anatomical structures. Post-traumatic lumbosacral plexus injuries with paraplegia, urinary retention and anorectal sphincter insufficiency occur quite frequently after heavy traffic accidents. Lumbosacral plexus injury as a result of rectal foreign body insertion is rare. Severe neurological deficits through rectal foreign body insertion are rare but known medical conditions. To the best of our knowledge, this is the first reported case of severe and persistent post-traumatic lumbosacral plexus injury through a rectal foreign body.

Injury to the Lumbar Plexus and its Branches After Lateral Fusion Procedures: A Cadaver Study.

INTRODUCTION: Neurologic deficits from lumbar plexus nerve injuries commonly occur in patients undergoing lateral approaches. However, it is not yet clear what types of injury occur, where anatomically they are located, or what mechanism causes them. We aimed to study 1) the topographic anatomy of lumbar plexus nerves and their injuries in human cadavers after lateral transpsoas approaches to the lumbar spine, 2) the structural morphology of those injuries, and 3) the topographic anatomy of the lumbar plexus throughout the mediolateral approach corridor. METHODS: Fifteen adult fresh frozen cadaveric torsos (26 sides) underwent lateral approaches (L1-L5) by experienced lateral spine surgeons. The cadavers were subsequently opened and the entire plexus dissected and examined for nerve injuries. The topographic anatomy of the lumbar plexus and its branches, their injuries, and the morphology of these injuries were documented. RESULTS: Fifteen injuries were found with complete or partial nerve transections (Sunderland IV and V). Injuries were found throughout the mediolateral approach corridor. At L1/2, the iliohypogastric, ilioinguinal, and subcostal nerves were injured within the psoas major muscle, the retroperitoneal space, or the outer abdominal muscles and subcutaneous tissues. Genitofemoral nerve injuries were found in the retroperitoneal space. Nerve root injuries occurred within the retroperitoneal space and psoas muscle. Femoral nerve injuries were found only within the psoas major muscle. No obturator nerve injuries occurred. CONCLUSIONS: Lateral approaches can lead to structural nerve damage. Knowledge of the complex plexus anatomy, specifically its mediolateral course, is critical to avoid approach-related injuries.

Immediate postpartum neurological deficits in the lower extremity: a prospective observational study.

BACKGROUND: Neurological deficits noted immediately after childbirth are usually various obstetric neuropathies, but prospective studies are limited. The main study aim was to quantify and describe immediate postpartum neurological deficits of the lower extremity, including the buttocks. METHODS: A prospective observational study of postpartum women delivering in a single maternity hospital during three months of 2016. Among 1147 eligible women, 1019 were screened for symptoms of lower extremity numbness or weakness within eight to 32hours of delivery. Consent to undergo a detailed neurological evaluation was sought from those reporting symptoms. Risk factors were identified using logistic regression. RESULTS: Thirty five women (3.4%) reported symptoms, 27 entered the study and 23 (2.0%) had objective signs of a neurological deficit. The most common injuries were mild lumbosacral plexopathies and cluneal nerve compression. Most deficits were sensory, half of these also having a motor deficit that did not impact functionally. Based on analysis of 22 cases involving a likely intrapartum deficit, no association was found with parity, body weight, duration of labour, mode of delivery or neuraxial block. A past history of a neurological condition or a back injury was associated with odds ratios of 7.98 and 4.82 respectively. There were no neurological deficits that were clinically concerning or that were likely a complication of a neuraxial block. CONCLUSION: Transient neurological complications after labour and delivery are infrequent, mainly sensory involving multiple lumbosacral nerve roots or specific sacral cutaneous nerves, and they typically resolve within a short time.