The effect of conventional radiofrequency thermocoagulation of femoral and obturator nerves' articular branches on chronic hip pain: a prospective clinical study.

BACKGROUND: Chronic hip pain is one of the most common and difficult-to-treat causes of disability. Our study's primary aim was to investigate the effects of ultrasound and fluoroscopy-guided radiofrequency thermocoagulation of the femoral and obturator nerve articular branches on chronic hip pain, and the secondary aim was to determine its effects on hip function and quality of life. METHODS: Fifty-three patients with hip pain lasting more than three months were enrolled in the study. VPS scale and WOMAC, SF-12 questionnaires were applied to the patients before and in the first, third, and sixth months following the procedure. RESULTS: Of the patients, 60.4% were female, and 39.6% were male. Hip pain was caused by osteoarthritis in 77.1%, postoperative hip pain in 12.5%, malignancy in 8.3%, and avascular necrosis in 2.1%. The VPS scores were 8.9 ± 1.1 (mean±SD) in the baseline period, 2.4 ± 2.5 in the first postoperative week, 3.8 ± 2.5 in the first month, 5.1 ± 2.8 in the third month, and 5.8 ± 2.7 in the sixth month, with a significant decrease in VPS score (P < .001). One patient developed a motor deficit that improved spontaneously. CONCLUSIONS: We concluded that radiofrequency thermocoagulation application to the articular branches of the femoral and obturator nerves provides pain relief, hip function improvement, and better quality of life (better physical component scores but no improvement in mental component scores in SF-12) for up to 6 months in chronic hip pain.

Variations of the extrapsoas course of the lumbar plexus with implications for the lateral transpsoas approach to the lumbar spine: a cadaveric study.

BACKGROUND: Together with an increased interest in minimally invasive lateral transpsoas approach to the lumbar spine goes a demand for detailed anatomical descriptions of the lumbar plexus. Although definitions of safe zones and essential descriptions of topographical anatomy have been presented in several studies, the existing literature expects standard appearance of the neural structures. Therefore, the aim of this study was to investigate the variability of the extrapsoas portion of the lumbar plexus in regard to the lateral transpsoas approach. METHODS: A total of 260 lumbar regions from embalmed cadavers were utilized in this study. The specimens were dissected as per protocol and all nerves from the lumbar plexus were morphologically evaluated. RESULTS: The most common variation of the iliohypogastric and ilioinguinal nerves was fusion of these two nerves (9.6%). Nearly in the half of the cases (48.1%) the genitofemoral nerve left the psoas major muscle already divided into the femoral and genital branches. The lateral femoral cutaneous nerve was the least variable one as it resembled its normal morphology in 95.0% of cases. Regarding the variant origins of the femoral nerve, there was a low formation outside the psoas major muscle in 3.8% of cases. The obturator nerve was not variable at its emergence point but frequently branched (40.4%) before entering the obturator canal. In addition to the proper femoral and obturator nerves, accessory nerves were present in 12.3% and 9.2% of cases, respectively. CONCLUSION: Nerves of the lumbar plexus frequently show atypical anatomy outside the psoas major muscle. The presented study provides a compendious information source of the possibly encountered neural variations during retroperitoneal access to different segments of the lumbar spine.

Anatomical and Radiological Assessments of Injectate Spread Stratified by the Volume of the Pericapsular Nerve Group Block.

BACKGROUND: The pericapsular nerve group (PENG) block was recently suggested as a regional technique for managing acute pain after hip surgery. However, few anatomical studies have confirmed the spread of injectate during the PENG block. This cadaver study aimed to analyze injectate spread to the target nerves during single-injection ultrasound-guided PENG block. METHODS: Ultrasound-guided PENG block with 3 different injectate volumes (10, 20, or 30 mL) was performed in 18 cadavers. Injectate spread by the volume was first evaluated on computed tomography, followed by cadaver dissection. The spread of the dye over the pelvis and lower limb was evaluated. RESULTS: The articular branches of the femoral nerve were stained nearly sufficiently with 20- and 30-mL specimens. The femoral nerve itself was stained simultaneously in six of 12 (50%) 20-mL specimens and 12 of 12 (100%) 30-mL specimens. The accessory obturator nerve was observed only in three (9%) of 36 specimens. The articular branches of the obturator nerve were rarely affected, regardless of injectate volume (1/12, 10 mL specimens; 2/12, 20 mL specimens; 1/12, 30 mL specimens; P > .999). Rather, the obturator nerve was affected. However, the obturator nerve was not stained consistently even with 30 mL of injectate (50%). CONCLUSIONS: After combining the dissection and radiological findings, the single-injection ultrasound-guided PENG blocks with volumes of 10, 20, and 30 mL do not support motor sparing or selective anterior hip capsule innervation in a clinical setting. If early rehabilitation is needed, high-volume PENG block might not be the ideal option, and persisting pain after PENG block might be attributed in part to the lack of obturator nerve articular branches blockade.

Selective Repair of Motor Branches in the Femoral Nerve by Transferring the Motor Branches of Obturator Nerve: An Anatomical Feasibility Study.

BACKGROUND: Anterior branch of the obturator nerve transfer has been proven as an effective method for femoral nerve injuries, but the patient still has difficulty in rising and squatting, up and downstairs. Here, we presented a novel neurotization procedure of selectively repairing 3 motor branches of the femoral nerve by transferring motor branches of the obturator nerve in the thigh level and assessing its anatomical feasibility. METHODS: Eight adult cadavers (16 thighs) were dissected. The nerve overlap distance between the gracilis branch and the rectus femoris (RF) branch, the adductor longus (AL) branch and the vastus medialis (VM) branch, as well as the adductor magnus (AM) branch and the vastus intermedius (VI) branch were measured. Also, the axon counts of the donor and recipient nerve were evaluated by histological evaluation. RESULTS: In all specimens, nerve overlap of at least 2.1 cm was observed in all 16 dissected thighs between the donor and recipient nerve branches, and the repair appeared to be without tension. There is no significant difference in the axon counts between gracilis branch (598 ± 83) and the RF branch (709 ± 151). The axon counts of the AL branch (601 ± 93) was about half of axon counts of the VM branch (1423 ± 189), and the axon counts of AM branch (761 ± 110) was also about half of the VI branch (1649 ± 281). CONCLUSIONS: This novel technique of the combined nerve transfers below the inguinal ligament, specifically the gracilis branch to the RF branch, the AL branch to the VM branch, and the AM branch to the VI branch, is anatomically feasible. It provides a promising alternative in the repair of femoral nerve injuries and an anatomical basis for the clinical application of motor branches of the obturator nerve transfer to repair the motor portion of the injured femoral nerve.

Cadaveric Study for Safe Elevation of a Profunda Artery Perforator Flap: Anatomy of the Perforators and Obturator Nerves.

BACKGROUND: This cadaveric study aimed to describe the anatomy of the profunda artery perforators (PAPs). METHODS: In total, nine free cadavers with 18 upper thighs were dissected, 12 of which were from female cadavers, and 6 were from male cadavers. The average age of the cadavers was 84.7 ± 4.2 years. Dissection was performed to evaluate the anatomic position and characteristics of the femoral PAPs. The perforator distance from the gluteal sulcus, number of perforators, perforating muscles, diameter of the perforators, origin of the perforators, and number of nerves passing above and below the perforators were determined. RESULTS: The average number of perforators that penetrate the adductor magnus muscle was 2.5. The average distance from the origin of the perforators to the gluteal sulcus was 71.72 ± 28.23 mm. The average numbers of the obturator nerves passing above and below the perforator in the adductor magnus muscle were 1.3 (range, 0-4) and 0.7 (range, 0-2), respectively. CONCLUSION: The results provide a detailed anatomic basis for the PAP flap. The perforators of a PAP flap may be included in a flap with a transverse design. Sacrificing the small obturator nerves during dissection may not lead to significant donor site morbidity.

Variations of the obturator nerve and implications in obturator nerve entrapment treatment: an anatomical study.

INTRODUCTION: Obturator nerve entrapment or idiopathic obturator neuralgia is an unfamiliar pathology for many physicians which can lead to diagnostic errancy. This study aims to identify the potential compression areas of the obturator nerve to improve therapeutic management. MATERIAL AND METHODS: 18 anatomical dissections of lower limbs from 9 anatomical cadavers were performed. Endopelvic and exopelvic surgical approaches were utilized to study the anatomical variations of the nerve and to identify areas of entrapment. RESULTS: On 7 limbs, the posterior branch of the obturator nerve passed through the external obturator muscle. A fascia between the adductor brevis and longus muscles was present in 9 of the 18 limbs. The anterior branch of the obturator nerve was highly adherent to the fascia in 6 cases. In 3 limbs, the medial femoral circumflex artery was in close connection with the posterior branch of the nerve. CONCLUSION: Idiopathic obturator neuropathy remains a difficult diagnosis. Our cadaveric study did not allow us to formally identify one or more potential anatomical entrapment zones. However, it allowed the identification of zones at risk. A clinical study with staged analgesic blocks would be necessary to identify an anatomical area of compression and would allow targeted surgical neurolysis.

Effectiveness and Safety of a Modified Technique of Transvesical Obturator Nerve Block to Avoid Adductor Contractions during Transurethral Resection of Bladder Tumors.

INTRODUCTION: The aim of the study was to evaluate the effectiveness of a modified transvesical obturator nerve block (ONB) in the prevention of obturator nerve reflex and consecutive bladder perforations (BPs) during transurethral resection of bladder tumors (TURBTs). MATERIALS AND METHODS: A retrospective analysis of all patients resected in 2014-2015 due to a bladder tumor of the lateral walls, including a follow-up period until December 2018, was performed. Two groups were defined: in the first group, all patients underwent TURBT with a modified transvesical ONB. The second group underwent conventional TURBT with intermittent resection. Primary endpoints were the rates of adductor contractions and BPs. RESULTS: Ninety-four out of 1,145 resected patients presented with tumors on the lateral wall of the bladder and a complete dataset including a long-term follow-up. Thirty-six patients were treated in the ONB group, and 58 patients comprised the control group. The median age in the 2 groups was 70.8 and 71.8 years in the first and second groups, respectively. Adductor spasms were reported in 8.33 versus 25.86% (p = 0.057) and perforation in 2.78 versus 17.24% (p = 0.047) in groups 1 and 2, respectively. After a median follow-up of 32.5 months, there was no significant difference in recurrence rates (52.78 vs. 51.72%, p = 0.672). In a subgroup analysis, lower perforation rates were recorded for the ONB group in patients with tumors <3 cm (0/30 vs. 8/46, p = 0.076) and in patients with unifocal tumors (0/12 vs. 5/23, p = 0.141). DISCUSSION/CONCLUSION: The simplified approach of transvesical ONB demonstrated in this study appears to be an inexpensive, safe, effective, and simple-to-use technique.

Successful restoration of knee extension after transferring of the anterior branch of the obturator nerve: a case study.

Objective: Femoral nerve palsy occurs after trauma, surgical procedures and tumors and leads to loss of quadriceps functions, disability and decreased quality of life. The aim of this report was to describe a successful restoration of knee extension by transferring the anterior branch of the obturator nerve to selective branches of the femoral nerve at the thigh level.Methods: We describe a 27-year-old male who had quadriceps femoris muscle paralysis after surgical evacuation for retroperitoneal hematoma five months ago. Since proximal stump of femoral nerve was not accessible, we transferred anterior branch of obturator nerve to selective branches of femoral nerve for reconstruction of quadriceps femoris muscle.Results: After four months, he regained quadriceps muscle strength M3 and began to walk. He achieved full muscle strength (M5) nine months after surgery and was able to walk up-stairs easily 14 months after surgery and atrophy of the quadriceps was improved.Conclusion: The anterior branch of the obturator nerve is an available donor nerve with an excellent functional recovery for the reconstruction of knee extension when proximal stump of femoral nerve is not reachable or the repair needs a long graft.

Femoral and sciatic nerve blockade of the pelvic limb with and without obturator nerve block for tibial plateau levelling osteotomy surgery in dogs.

OBJECTIVE: To determine the effect of blocking the obturator nerve in addition to performing femoral nerve and sciatic nerve blocks on intraoperative nociception in dogs undergoing unilateral tibial plateau levelling osteotomy (TPLO) surgery. STUDY DESIGN: Prospective, blinded, randomized, placebo-controlled, clinical comparison. ANIMALS: A total of 88 client-owned dogs undergoing unilateral TPLO surgery (100 procedures). METHODS: Dogs were randomly assigned to either group FSO (femoral, sciatic and obturator nerve blocks) [n = 50; ropivacaine 0.75% (0.75 mg kg-1)] or group FSP (femoral, sciatic and placebo) [n = 50; ropivacaine 0.75% (0.75 mg kg-1) femoral and sciatic nerve blocks plus saline solution 0.9% (0.1 mL kg-1) as a placebo injection around the obturator nerve]. The anaesthetic protocol was standardized. Data collection included intraoperative cardiopulmonary variables and opioid consumption. Rescue analgesia consisted of an intravenous bolus of fentanyl (2 µg kg-1) and was administered when a change in cardiopulmonary variables (20% increase in mean arterial pressure or heart rate) was attributed to a sympathetic stimulus. Data were analysed using generalized linear mixed models, cross tables and multivariable binary logistic regression. Results were expressed as adjusted odds ratios with 95% confidence intervals and Wald p values (α = 0.05). RESULTS: There were no clinically relevant differences between groups in intraoperative cardiopulmonary variables and need for rescue analgesia. The requirement for rescue analgesia was significantly higher in dogs with a body weight >34 kg. CONCLUSIONS AND CLINICAL RELEVANCE: Anaesthesia of the obturator nerve in addition to the femoral and sciatic nerves was not associated with clinically significant differences in cardiopulmonary variables or a reduced need for rescue analgesia. Therefore, the clinical benefit of an additional obturator nerve block for intraoperative antinociception in dogs undergoing unilateral TPLO surgery using the described anaesthetic regimen is low.

Comparison of three obturator nerve block techniques for injectate spread into the obturator canal: a randomized controlled trial.

PURPOSE: The obturator nerve branches into the obturator canal; therefore, local anesthetic spread into the obturator canal predicts the success of the obturator nerve block (ONB). We compared three ONB techniques for the spread of local anesthetic mixed with contrast medium into the obturator canal. METHODS: We performed the ONB using the classical pubic approach (PA), inguinal approach (IA), or ultrasound-guided methodologic approach (UMA) in 143 patients undergoing transurethral resection of bladder tumors. The obturator nerve course and branching patterns of the UMA group were examined using ultrasound imaging. After injecting a local anesthetic mixed with a contrast medium, we evaluated its spread into the obturator canal using fluoroscopic imaging. P < 0.05 indicated statistical significance. RESULTS: Success rate of obturator canal enhancement was the greatest in the UMA group (84%; P < 0.001); the PA (42.6%; 20/47 patients) and IA (47.8%; 22/46 patients) groups did not differ significantly (P = 1.000). Both branches of the obturator nerve passed above the superior margin of the external obturator muscle (EOM), and the obturator canal was enhanced in 13 of 50 (26%) patients in the UMA group. The posterior branch of the obturator nerve passed between the superior and main fasciculi of the EOM in 37 of 50 patients (74%) in the UMA group; the obturator canal was enhanced in 29 of these 37 patients (78%). CONCLUSION: Local anesthetic spread into the obturator canal using the UMA was superior to that using the PA and IA. Both branches of the obturator nerve could be blocked using the UMA.

Innervation of the scrotum by the anterior division of the obturator nerve - a rare variation.

The scrotum is supplied by ilioinguinal, genital branch of genitofemoral, perineal branch of the posterior cutaneous nerve of the thigh and the posterior scrotal branches of the pudendal nerve. We report an extremely rare innervation of the anterior part of the scrotum by the anterior division of the right obturator nerve. The genital branch of genitofemoral nerve did not reach the scrotum. The ilioinguinal nerve did not supply the scrotum. The anterior division of the obturator nerve gave a branch which ascended superomedially in the thigh, crossed superficial to the spermatic cord and communicated with the right ilioinguinal nerve. As it crossed the spermatic cord, it gave a scrotal branch which descended over the spermatic cord and ramified to supply the anterior part of the scrotum. Knowledge of this variation could be important to anaesthesiologists, urologists and surgeons in general.

Transanterior obturator nerve gateway: a novel approach to achieving intracorporeal distal rectal transection for ultralow rectal cancer.

BACKGROUND: Intracorporeal rectal transection at the anorectal junction for ultralow rectal cancer is technically difficult due to pelvic width and limited roticulation, which might require a transanal transection or an oblique transection with multiple firings. These procedures were reported to be associated with the increased risk of morbidity. To address these problems, we presented a novel technique Transanterior Obturator Nerve Gateway (TANG) to transect rectum for ultralow rectal cancer and evaluated its safety and feasibility in this study. METHODS: A total of 210 consecutive patients who underwent laparoscopic coloanal anastomosis with or without partial intersphincteric resection (CAA/pISR) for rectal cancers between January 2017 and January 2020 were included. Eighty of these patients were analyzed using propensity score matching (PSM). The perioperative characteristics, TANG-related variables, and genitourinary and anal function outcomes were analyzed. RESULTS: Among these enrolled patients, 170 patients underwent traditional transection, and 40 underwent TANG transection; the patients were matched to include 40 patients in each group by PSM. After PSM, there were no significant differences in the operating time (p = 0.351) or bleeding volume (p = 0.474) between the two groups. However, the TANG group had fewer cases of conversion to transanal transection (0 vs. 13, p < 0.001). Moreover, the patients in TANG group had a more desirable transection with longer distal resection margin (1.7 vs. 1.1 cm, p < 0.001), shorter stapling line (6.6 vs. 10.3 cm, p < 0.001) and fewer stapler firings (p < 0.001). The overall postoperative complication rates and genitourinary and anal function outcomes were not significantly different between the two groups. CONCLUSIONS: The TANG approach appears to be a safe, feasible and effective approach for intracorporeal ultralow rectal transection with more distal resection, more vertical transection and fewer stapler firings.

Sensory Innervation of the Hip Joint and Referred Pain: A Systematic Review of the Literature.

OBJECTIVES: The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches innervating the hip joint and the distribution of sensory receptors within its capsule. METHODS: Five electronic databases were queried, with the search encompassing articles published between January 1945 and June 2019. Twenty-one original articles providing a detailed description of sensory receptors around the hip joint capsule (n=13) and its articular branches (n=8) were reviewed. RESULTS: The superior portions of the anterior capsule and the labrum were found to be the area of densest nociceptive innervation. Similar to the distribution of nociceptors, mechanoreceptor density was found to be higher anteriorly than posteriorly. Hip joint capsular innervation was found to consistently involve the femoral and obturator nerves, which supply the anterior capsule, and the nerve to the quadratus femoris, which supplies the posterior capsule. The femoral, obturator, and superior gluteal nerves supply articular branches to the most nociceptor-rich region of the hip capsule. CONCLUSIONS: The femoral and obturator nerves and the nerve to the quadratus femoris were found to consistently supply articular branches to both the anterior and posterior capsule of the hip joint. The anterior capsule, primarily supplied by the femoral and obturator nerves, and the superior labrum appear to be the primary pain generators of the hip joint, given their higher density of nociceptors and mechanoreceptors. LEVEL OF EVIDENCE: Anatomy study, literature review.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery.

PURPOSE OF REVIEW: Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients. RECENT FINDINGS: FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.

Peritoneal Retraction Pocket Defects and Their Important Relationship with Pelvic Pain and Endometriosis.

OBJECTIVE: The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. DESIGN: Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1-4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [7,8], patients may present with thigh adduction weakness or difficulty ambulating [9,10]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms. CONCLUSION: Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

Laparoscopic repair of segmental obturator nerve injury defect using an artificial nerve conduit: A case report.

Obturator nerve injury is an uncommon complication frequently associated with pelvic gynecologic or urologic cancer surgery. It can lead to disability or adversely affect quality of life. Large segmental defects are particularly difficult to manage as the limited mobility of the nerve prevents tension-free direct end-to-end anastomosis. A 36-year-old woman with cervical cancer underwent sentinel lymph node biopsy, laparoscopic radical hysterectomy, and bilateral adnexectomy. During the procedure, the sentinel lymph node (right obturator node) adherent to the obturator nerve was resected together with the nerve segment leaving a 3 cm defect. Immediate laparoscopic obturator nerve repair was performed using an artificial nerve conduit leading to successful recovery. We report this unique case due to rarity of large segmental obturator nerve defects and present laparoscopic nerve repair with artificial nerve conduits as a useful treatment alternative of these important injuries, without nerve donor site morbidity.

Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries.

INTRODUCTION: The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. METHODS: A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. RESULTS: Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. DISCUSSION: The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Contralateral obturator nerve transfer for femoral nerve restoration: a case report.

BACKGROUND: Femoral nerve injury may occur in severe traffic accident injuries with pelvic fracture. Sural nerve grafts or ipsilateral obturator nerve transfer may be used to restore femoral nerve function. We report a new procedure transferring the contralateral obturator nerve to restore femoral nerve function. CASE DESCRIPTION: A 30 year-old male suffering complete lumbar plexus rapture received a contralateral obturator nerve transfer in our hospital. At 2 years follow up he had gained Medical Research Council Grade 3 muscle strength in his 23th months follow-up, with normal gait, Lower Extremity Functional Scale score of 58.75% and Femoral Nerve Motor Function Scale score 61%. CONCLUSION: The contralateral obturator nerve transfer is a reliable alternative if the nerve graft or ipsilateral obturator nerve cannot be performed.

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

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

[Analysis of the results of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis.]

The aim of the study was to analyze the results of the use of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis. The results of treatment of 34 patients over 65 years of age with symptomatic degenerative diseases of the hip joint (HJD) and somatic contraindications for total hip arthroplasty have been prospectively studied. In the study group, in the period from 2017 to 2019, laser destruction of the articular branch of the obturator nerve (970 nm, frequency 9 Hz and power 3 W in a total dose of 100 J) was carried out. The average follow-up was 12 months. To assess the effectiveness of surgical treatment, the dynamics of the pain syndrome in the hip joint was analyzed according to the visual analogue scale, the quality of life according to the SF-36 questionnaire, the functional state of the hip joint according to the W.H.Harris scale and the presence perioperative surgical complications. As a result, it was found that the use of laser destruction of the articular branch of the obturator nerve in degenerative coxarthrosis in elderly and senile patients (if total hip arthroplasty was not possible) made it possible to significantly reduce the level of preoperative pain syndrome, restore the quality of life and improve the functional state of patients with low risks of surgical complications.