Subcapsular relocation for sacral neuromodulation pulse generator implant revision

Objectives: We describe our technique and experience with subcapsular placement of the Interstim (Medtronic, Minneapolis, MN, USA) pulse generator in cases of revision for implant site pain. Methods: The pulse generator and electrode are carefully exteriorized and the floor of the capsule is incised. The system is placed beneath the floor of the original capsule, which then becomes the roof of the new pocket. A layered closure is performed. Results: Five patients have undergone the technique described with successful resolution of their pain. Conclusions Utilizing the capsule presumably improves defects in skin microcirculation, but also creates additional cushion superior to the pulse generator, helping to counteract the vertical mechanical forces of the pulse generator.     

显微手术治疗骶管Tarlov囊肿

目的探讨骶管Tarlov 囊肿(骶管囊肿)临床特点和手术治疗。方法回顾性分析25例有症状的骶管囊肿临床和影像学特点。结果术后早期25例中21例症状缓解。24例随访3～48个月(平均18月),囊肿未见复发。19例患者症状消失或明显改善,5例仍存在疼痛及麻木不适感,不影响生活及工作。结论对有明确症状的骶管囊肿患者应采取显微手术治疗。手术方式根据骶管囊肿的不同类型,采取囊肿交通孔结扎囊壁切除,或囊肿大部切除神经袖套塑形的方法,并采取带蒂脂肪填塞囊肿切除后遗留的残腔。     

Rapid rate magnetic stimulation of human sacral nerve roots alters excitability within the cortico‐anal pathway

Abstract Sacral nerve root stimulation (SNS) can produce dramatic symptomatic improvement in faecal incontinence (FI). However, the physiological mechanism behind this improvement remains unknown. One hypothesis is that SNS may modulate cortico‐anal pathways and drive compensatory changes within the spinal cord or cerebral cortex that beneficially alter sphincter function. Our aim was to assess whether short‐term experimental SNS can induce changes in the human cortico‐anal pathway. Eight healthy volunteers (mean age 30 years) were studied. Subjects were investigated on three separate occasions and randomized to either active (5 and 15 Hz) or sham rapid‐rate lumbosacral magnetic stimulation (rLSMS). Anal sphincter electromyograms (EMG) were recorded from an anal probe following single‐pulse transcranial magnetic stimulation, at baseline, immediately, 30 and 60 min following rLSMS at either (i) 5 Hz for 15 min, (ii) 15 Hz for 15 min or (iii) sham stimulation for 15 min. In addition, manometry and anal sphincter sensation was measured in a subset of subjects. Interventions were compared to sham using anova . Fifteen hertz rLSMS increased cortico‐anal EMG response amplitude in the 1 h postintervention (F_{4, 28} = 3.2, P = 0.027), without a shift in response latency. This effect was not demonstrated with either 5 Hz or sham stimulation. rLSMS had no short‐term effect on sensation or physiology. Short‐term magnetic stimulation of the sacral nerve roots induces changes in cortico‐anal excitability which is frequency specific. These data support the hypothesis that SNS produces some of its beneficial effect in patients with FI by altering the excitability of the cortico‐anal pathway.     

Rectal motility after sacral nerve stimulation for faecal incontinence

Abstract  Sacral nerve stimulation (SNS) is effective against faecal incontinence, but the mode of action is obscure. The aim of this study was to describe the effects of SNS on fasting and postprandial rectal motility. Sixteen patients, 14 women age 33–73 (mean 58), with faecal incontinence of various aetiologies were examined. Before and during SNS, rectal cross-sectional area (CSA) and ano-rectal pressures were determined with impedance planimetry and manometry for 1 h during fast and 1 h postprandially. Neither in the fasting state nor postprandially did SNS affect the number of single rectal contractions, total time with cyclic rectal contractions, the number of aborally and orally propagating contractions, the number of anal sampling reflexes or rectal wall tension during contractions. Postprandial changes in rectal tone were significantly reduced during SNS ( P  < 0.02). Before SNS, median rectal CSA was 2999 mm² (range: 1481–3822) during fast and 2697 mm² (range: 1227–3310) postprandially ( P  < 0.01). During SNS, median rectal CSA was 2990 mm² (1823–3678) during fast and 2547 mm² (1831–3468) postprandially ( P  = 0.22). SNS for faecal incontinence does not affect phasic rectal motility but it impairs postprandial changes in rectal tone.     

Prolonged electrical stimulation causes no damage to sacral nerve roots in rabbits

Previous studies have shown that, anode block electrical stimulation of the sacral nerve root can produce physiological urination and reconstruct urinary bladder function in rabbits. However, whether long-term anode block electrical stimulation causes damage to the sacral nerve root remains unclear, and needs further investigation. In this study, a complete spinal cord injury model was established in New Zealand white rabbits through T9–10 segment transection. Rabbits were given continuous electrical stimulation for a short period and then chronic stimulation for a longer period. Results showed that compared with normal rabbits, the structure of nerve cells in the anterior sacral nerve roots was unchanged in spinal cord injury rabbits after electrical stimulation. There was no significant difference in the expression of apoptosis-related proteins such as Bax, Caspase-3, and Bcl-2. Experimental findings indicate that neurons in the rabbit sacral nerve roots tolerate electrical stimulation, even after long-term anode block electrical stimulation.     

New selective endoscopic sacral nerve root stimulation – an advance in the treatment of fecal incontinence

Background Fecal incontinence (FI) is a major part of illness and physical discomfort in the general population. Since the 1990s, sacral nerve stimulation has been well established in the treatment of neurogenic FI. The precise placement of the electrode is crucial for the success of the procedure. Eighty percent of the patients benefit from permanent treatment, but in 10–20% of the patients tested electrode placement proves impossible due to anatomical variations of the sacral foramina. In this study, we describe the technical requirements and a new method of electrode placement with reference to the anatomical (bone) landmarks in an animal model. Methods With a small endoscope (Verres needle), we accessed the perirectal space to identify the nervous structures. A stimulated sphincter EMG was obtained for the experimental animals and muscle action potential (MAP/M‐wave), latency time [ms], and the amplitude of the motor response [μV] were recorded. Electrodes were placed, the animals killed and dissected leaving the pelvic cavity untouched. The specimens were examined in a magnetic resonance scanner and in a multi‐slice computed tomography scanner to detect the electrode material and possible surgical complications. After that the specimens were dissected. Key Results In all eight cases in the four animals tested, we were able to stimulate the sacral nerve as demonstrated by the EMG findings. No major surgical complications were observed for the procedure. Conclusions & Inferences Endoscopic sacral nerve root stimulation is a safe and effective method for delivering stimulation material in the pelvis of the sheep. It is a promising procedure to be tested in humans.     

Does magnetic stimulation of sacral nerve roots modify colonic motility? Results of a randomized double‐blind sham‐controlled study

Abstract  Although sacral nerve root stimulation (SNS) can result in a symptomatic improvement of faecal incontinence, the mechanism of action remains unknown. The aim of this study was to assess whether short-term magnetic SNS can inhibit pharmacologically induced propulsive colonic contractions. Twelve healthy volunteers (median age: 43.5 years old) were studied on two separate occasions and randomized into either active (15 Hz, 100% output intensity for 5 s min⁻¹ for 30 min) or sham rapid rate lumbosacral magnetic stimulation (rLSMS). Colorectal motility was recorded with a manometric catheter located at the most proximal transducer in the left colon and the most distal, in the rectum. Colonic contractions were provoked by instilling Bisacodyl. The effects of rLSMS on colonic, sigmoid and rectal contractions were monitored and recorded after Bisacodyl instillation. The appearance of high-amplitude contractions propagated or not (HAC/HAPC) provoked by Bisacodyl instillation was significantly delayed during active compared to sham stimulation ( P  = 0.03). There was no difference in the characteristics of HAC/HAPC (i.e. frequency, amplitude, duration, velocity of propagation) or the motility index with active or sham stimulation. The perception of urgency tended to be decreased with rLSMS following Bisacodyl instillation. The catheter was expulsed within a median of 16.5 min (range 8–39) after Bisacodyl administration during active stimulation compared to 14 min (range 5–40) during sham stimulation ( P  = 0.03). This study suggests that rLSMS could delay the appearance of the first Bisacodyl-induced colonic contractions.     

The laparoscopic implantation of neuroprothesis to the sacral plexus for therapy of neurogenic bladder dysfunctions after failure of percutaneous sacral nerve stimulation

Objectives: To report about our first short series of laparoscopic implantation of neuroprothesis—LION procedure—to the sacral plexus for treatment of different neurogenic bladder dysfunctions in patients in whom percutaneous sacral nerve stimulation (SNS) failed. Material and Methods: A unilateral sacral LION procedure was performed in four patients with a refractary interstitial cystitis, in 13 patients with refractory bladder overactivity (multiple sclerosis N= 8, spina bifida N= 1, incomplete paraplegia N= 2, diabetic cystopathy N= 1), one patient with a neurogenic bladder incontinence by Parkinson syndrome, and in four patients for treatment for bladder atonia (Fowler's syndrome). In all patients, not only previous medical treatments but also SNS by transforaminal implantation had failed. Laparoscopic exposure of the sacral nerves roots S2 to S4/5 is performed by a transperitoneal approach and a quad electrode is placed perpendicular to the sacral nerve roots for postoperative global stimulation of these sacral nerve roots. Results: All procedures were performed successfully by laparoscopy without any complications. The mean operative time for such a procedure was 34 min. In two patients of the series postoperative neuromodulation failed. In all further 19 patients with an actual follow‐up varying between three months and three years, neuromodulation is still working successfully. Conclusions: Our results underscore that the sacral LION procedure to the sacral plexus is effective and safe for treatment divers neurogenic bladder dysfunctions even after failure of the classical percutaneous technique of implantation.     

骶管内囊肿的显微外科治疗

目的探讨骶管内囊肿的诊断及治疗措施。方法总结27例骶管内囊肿患者的临床表现、影像学特征、是否合并脊髓栓系、显微手术方法和术后疗效及围手术期并发症。结果囊肿完整切除18例,部分切除9例;囊肿切除后,空腔填塞脂肪18例;术后2例出现脑脊液漏,经腰大池引流后治愈。结论 MRI检查是确诊骶管蛛网膜囊肿的有力手段,伴有临床症状、体征者应考虑手术治疗。对囊肿的处理以囊肿切除、严密结扎漏口为主,术中填塞脂肪、严密缝合切口各层及术后合理体位可以有效防止囊肿复发。     

骶前脊膜膨出的临床治疗

目的探讨骶前脊膜膨出患者手术方法。 方法对滨州医学院附属医院神经外科2015年4月收治的1例骶前脊膜膨出患者进行回顾性分析,探讨骶前脊膜膨出的诊断、治疗方法。 结果采用骶后入路吸出囊液,结扎囊颈,术后患者症状消失,功能改善。3个月随访MRI,可见盆腔内、骶前区病变液性暗区消失,囊肿无复发。 结论单纯骶前脊膜膨出采用骶后入路手术安全便捷,值得临床应用及推广。     

Purulent meningitis due to spontaneous anterior sacral meningocele perforation. Case report

A 36 year old women with anterior sacral meningocele developed a purulent meningitis secondary to the rupture of the meningeal sac into the rectum. The value of neuroradialogical studies, especially CT, is emphasized.

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Sommario Gli Autori descrivono un caso di meningite purulenta insorta in una donna in seguito alla rottura spontanea nel retto di un meningocele sacrale anteriore. Viene inoltre confermato il ruolo della tomografia computerizzata in tale patologia.

     

骶骨前脊膜膨出的研究进展

骶骨前脊膜膨出(ASM)是硬脊膜和蛛网膜通过骶骨前方的异常骨性缺损向盆腹腔突出形成的疝囊,临床症状与囊肿对周围组织的压迫程度以及合并的其他病变有关,主要表现为大小便功能障碍、头痛、腰骶神经功能异常等.ASM发病率低,临床表现多样化,容易被误诊,需普外科、泌尿外科、妇产科以及神经外科等多学科医师加深认识.目前,ASM的治疗主要以手术治疗为主,且有多种手术方式,需根据每个患者的具体病情选择最有利的手术方式来确保手术的安全与成功.该文对ASM的发病机制、临床表现、诊断方式、手术方法以及临床治疗策略进行综述,为ASM的诊治提供参考.