Anatomy & Embryology
Manit Arya, Taimur T. Shah, Jas S. Kalsi, Herman S. Fernando, Iqbal S. Shergill, Asif Muneer, Hashim U. Ahmed in MCQs for the FRCS(Urol) and Postgraduate Urology Examinations, 2020
The autonomic nervous system provides sympathetic and parasympathetic supply to organs, blood vessels, glands and smooth muscle. The somatic system innervates skin, skeletal muscles and joints. Parasympathetic fibres arise from cranial and sacral spinal nerves, whilst sympathetic fibres for the thoracolumbar region originate from spinal nerves T1 to L3. The two sympathetic chains lie anteriorly on either side of the vertebral column to which the preganglionic fibres synapse. These fibres then continue via splanchnic nerves to the coeliac or superior and inferior plexuses associated with the aorta to synapse with postganglionic fibres that supply the target organ. Preganglionic fibres also directly supply the adrenal gland. The coeliac plexus is closely associated with the coeliac trunk and is where a significant proportion of the autonomic supply to the kidneys, adrenals, renal pelvis and ureters pass through. The superior hypogastric plexus lies below this near the aortic bifurcation and connects with the inferior hypogastric plexus below. Any disruption here during retroperitoneal lymph node dissection can result in retrograde ejaculation. The somatic lumbosacral plexus is formed from spinal nerves L1 to S3 and provides innervation to the abdomen and lower extremities. The major nerves of the plexus are described in the following table.
Nerve and Root Lesions
John W. Scadding, Nicholas A. Losseff in Clinical Neurology, 2011
Other causes of root pain need consideration, although these are less common. Diabetic infarction of nerve roots, the plexus or femoral nerve, may present with acute pain in the thigh and be accompanied by wasting, impaired reflexes and sensory loss. Neoplastic involvement of nerve roots may arise in the spinal canal, often secondary to bony metastases with collapse of the vertebrae, most often from primary tumours of bronchus, breast, prostate, kidney, gastrointestinal tract or lymphomas. The lumbosacral plexus on the side wall of the pelvis may be involved with gynaecological or colonorectal malignancies. Such tumours cause severe pain, which is often not relieved by rest, unlike the pain from a disc. In time, the lymphatic pathways and even the iliac veins may be obstructed, leading to swelling of the leg.
Trunk
Rui Diogo, Drew M. Noden, Christopher M. Smith, Julia Molnar, Julia C. Boughner, Claudia Barrocas, Joana Bruno in Understanding Human Anatomy and Pathology, 2018
The spinal nerves divide into ventral rami and dorsal rami. The ventral rami form the intercostal nerves (T1–T12) in the thoracic region, as well as the cervical plexus, brachial plexus, lumbar plexus, and sacral plexus, thereby supplying the muscles and skin of the upper and lower limbs and part of the trunk. The lumbar plexus, sacral plexus, and pudendal plexus form the lumbosacral plexus. Intercostal nerves T1 to T11 lie together with the intercostal veins and intercostal arteries in the 11 intercostal spaces, while T12 is a subcostal nerve that courses below the 12th rib. The anterior end of an intercostal space is supplied by the anterior intercostal branches of the internal thoracic artery. The intercostal nerves supply the serratus posterior superior and serratus posterior inferior and the external intercostal muscle, internal intercostal muscle, and innermost intercostal muscle. The intercostal nerves also have cutaneous branches at the anterior (ventral) and lateral surfaces of the thoracic wall. The dorsal rami supply the paravertebral muscles (paraspinal muscles) and skin near the midline of the back.
Differential diagnosis of knee pain following a surgically induced lumbosacral plexus stretch injury. A case report
Published in Physiotherapy Theory and Practice, 2019
William R. VanWye, Harvey W. Wallmann, Elizabeth S. Norris, Karen E. Furgal
The onset of the patient’s symptoms coincided with the recent D&C procedure, which was performed in the lithotomy position. Lithotomy positioning can result in stretch injuries to the femoral, lateral femoral cutaneous, obturator, sciatic, or common peroneal nerves (Barnett et al, 2007). It can also result in a lumbosacral plexus stretch injury, which is more consistent with the patient’s presentation (Flanagan, Webster, Brown, and Massey, 1985). Identifying the pattern of weakness and numbness clinically after a lumbosacral plexus injury may be difficult (Flanagan, Webster, Brown, and Massey, 1985; Preston and Shapiro, 2013). The patient exhibited hamstring weakness, which is innervated by the sciatic nerve, as well as weakness of the left ankle plantarflexors (i.e. gastrocnemius and soleus muscles), which are innervated by the tibial branch of the sciatic nerve (Kendall, McCreary, Provance, and Kendall, 1999). Yet, the patient also had left gluteus maximus and medius weakness, which are innervated by the inferior and superior gluteal nerve, respectively. The potential pattern in this case; each of these muscles is partially supplied by the S1 nerve root (Kendall, McCreary, Provance, and Kendall, 1999).
Efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for uterine fibroids: an observational single-center study
Published in International Journal of Hyperthermia, 2021
Milka Marinova, Shiwa Ghaei, Florian Recker, Tolga Tonguc, Olga Kaverina, Oleksandr Savchenko, Dmitrij Kravchenko, Marcus Thudium, Claus C. Pieper, Eva K. Egger, Alexander Mustea, Ulrike Attenberger, Rupert Conrad, Dariusch R. Hadizadeh, Holger Strunk
Our study confirmed that HIFU is a safe and low-risk procedure. While the method is per se noninvasive and no serious complications or permanent damage were observed, the procedure itself is associated with peri-procedural pain in up to 80% of patients [35]. This pain almost immediately disappeared after treatment returning to pretreatment levels within a few hours post-procedure [33,36]. This may be due to energy absorption and swelling of the tissue (skin, fat, abdominal wall) in the acoustic access path, which is usually clinically inapparent, but could be detected in about every sixth patient using MRI [32]. In contrast to interventions, e.g., in pancreatic carcinoma, which is usually performed under general anesthesia, HIFU treatment for fibroids is usually carried out in conscious sedation. As a result, patients are responsive and can provide feedback for treatment adjustment if the energy application causes irritation of the lumbosacral plexus. However, in our study, there were no such adverse effects lending further evidence to the safety of the procedure. Care may be required in HIFU treatment of uterine fibroids located on the posterior uterine wall or in retroverted uteri, close to the surface of the sacral bone adjacent to lumbosacral nerves, to prevent sciatic nerve damage or sacral injury [37,38]. Occurring in approximately 4–14% of patients, such transient irritation is one of the most frequently reported side effects, along with vaginal discharge (6%) [19,27,37,38], which was reported in 10% of our patients. Serious side effects like skin burns (up to 2%) or even small bowel perforations (0.1%) are possible but have been only rarely reported [7,39]. Nonetheless, compared to other treatment options, such as myomectomy or hysterectomy HIFU treatment is the procedure with the lowest short-term complication rate [5].
Distal Stimulation Site at the Medial Tibia for Saphenous Nerve Somatosensory Evoked Potentials (DSn-SSEPs) in Lateral Lumbar Spine Procedures
Published in The Neurodiagnostic Journal, 2021
Kathryn Overzet, Derrick Mora, Eloise Faust, Lindsay Krisko, Dyanne Welch, Faisal R. Jahangiri
The root contributions of the lumbosacral plexus and the femoral nerve trunk are often encountered in the surgical field of lateral lumbar procedures. The lumbar plexus is formed by the first four lumbar nerves (L1–4) and the subcostal nerve (T12). The plexus passes through the iliopsoas muscle and runs obliquely down the pelvis. The femoral nerve (L2–4) is the largest branch in the lumbar plexus and innervates the skin of the medial thigh and the muscles that extend the lower leg (Moore et al. 2017).